Errors in bladder catheterization: are residents ready for complex scenarios?

BACKGROUND: The aim of this study was to investigate whether junior surgical residents had successfully mastered bladder catheterization. Our hypothesis was that surgical residents would be overly confident in their abilities and underestimate the potential for case complexity. MATERIALS AND METHODS: PGY 2-4 surgery residents (n = 44) were given 15 min. to complete three of four bladder catheterization simulations. Participants reported their mastery by rating confidence using a 5-point Likert scale. Multiple linear regression analysis was used to test predictors of procedure performance. RESULTS: Participants made a total of 228 errors with an average of 5.1 errors (standard deviation = 2.6) per participant. The most common errors included not maintaining the sterile field (52.0%), failure to get urine return (20.3%), and inflating the catheter balloon before urine return (8.4%). Some residents committed the same error more than once. Presimulation confidence ratings ranged from "1" being not confident to "5" being extremely confident. Average presimulation confidence was 4.42 (range 1-5, standard deviation = 0.85). Sixteen (36%) residents ranked their presimulation confidence in problem-solving abilities as "moderately confident" or below, whereas 28 (64%) were "very confident" or above. The lower the resident's presimulation confidence in problem-solving, the more errors they committed during the simulation (beta = -0.33, t = -2.15, P = 0.04). CONCLUSIONS: The residents did not perform as well as they anticipated when presented with more complicated bladder catheterization scenarios. Simulation can be used to identify and expose potential errors that may occur during complex presentations of basic procedures. This type of training and assessment may facilitate mastery.

Do resident's leadership skills relate to ratings of technical skill?

BACKGROUND: This study sought to compare general surgery research residents' survey information regarding self-efficacy ratings to their observed performance during a simulated small bowel repair. Their observed performance ratings were based on their leadership skills in directing their assistant. METHODS: Participants were given 15 min to perform a bowel repair using bovine intestines with standardized injuries. Operative assistants were assigned to help assist with the repair. Before the procedure, participants were asked to rate their expected skills decay, task difficulty, and confidence in addressing the small bowel injury. Interactions were coded to identify the number of instructions given by the participants to the assistant during the repair. Statistical analyses assessed the relationship between the number of directional instructions and participants' perceptions self-efficacy measures. Directional instructions were defined as any dialog by the participant who guided the assistant to perform an action. RESULTS: Thirty-six residents (58.3% female) participated in the study. Participants who rated lower levels of decay in their intraoperative decision-making and small bowel repair skills were noted to use their assistant more by giving more instructions. Similarly, a higher number of instructions correlated with lower perceived difficulty in selecting the correct suture, suture pattern, and completing the entire surgical task. CONCLUSIONS: General surgery research residents' intraoperative leadership skills showed significant correlations to their perceptions of skill decay and task difficulty during a bowel repair. Evaluating resident's directional instructions may provide an additional individualized intraoperative assessment metric. Further evaluation relating to operative performance outcomes is warranted.

Resident performance in complex simulated urinary catheter scenarios.

BACKGROUND: Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter-associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision-making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations. METHODS: Forty-five general surgery residents (postgraduate year 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 min to complete the scenarios with five different urinary catheter choices. A chi-square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision-making for each scenario. RESULTS: Eighty-two percent of residents performed scenario A; 49% performed scenario B; 64% performed scenario C, and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, P's < 0.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, P < 0.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (P < 0.001). Chi-square analyses showed no relationship between residents' first and subsequent catheter choices for each scenario (P's > 0.05). CONCLUSIONS: Evaluation of clinical decision-making shows that initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision-making with regard to urinary catheter choices in residents.

Residents' perception of skill decay during dedicated research time.

BACKGROUND: Surgery residents may take years away from clinical responsibilities for dedicated research time. As part of a longitudinal project, the study aim was to investigate residents' perceptions of clinical skill reduction during dedicated research time. Our hypothesis was that residents would perceive a greater potential reduction in skill during research time for procedures they were less confident in performing. MATERIALS AND METHODS: Surgical residents engaged in dedicated research training at multiple training programs participated in four simulated procedures: urinary catheterization, subclavian central line, bowel anastomosis, and laparoscopic ventral hernia (LVH) repair. Using preprocedure and postprocedure surveys, participants rated procedures for confidence and difficulty. Residents also indicated the perceived level of skills reduction for the four procedures as a result of time in the laboratory. RESULTS: Thirty-eight residents (55% female) completed the four clinical simulators. Participants had between 0-36 mo in a laboratory (M = 9.29 mo, standard deviation = 9.38). Preprocedure surveys noted lower confidence and higher perceived difficulty for performing the LVH repair followed by bowel anastomosis, central line insertion, and urinary catheterization (P < 0.05). Residents perceived the greatest reduction in bowel anastomosis and LVH repair skills compared with urinary catheterization and subclavian central line insertion (P < 0.001). Postprocedure surveys showed significant effects of the simulation scenarios on resident perception for urinary catheterization (P < 0.05) and LVH repair (P < 0.05). CONCLUSIONS: Residents in this study expected greater skills decay for the procedures they had lower confidence performing and greater perceived difficulty. In addition, carefully adapted simulation scenarios had a significant effect on resident perception and may provide a mechanism for maintaining skills and keeping confidence grounded in experience.

Operative skill: quantifying surgeon's response to tissue properties.

BACKGROUND: The aim of this study was to investigate how tissue characteristics influence psychomotor planning and performance during a suturing task. Our hypothesis was that participants would alter their technique based on tissue type with each subsequent stitch placed while suturing. MATERIALS AND METHODS: Surgical attendings (n = 6), residents (n = 4), and medical students (n = 5) performed three interrupted sutures on different simulated materials as follows: foam (dense connective tissue), rubber balloons (artery), and tissue paper (friable tissue). An optical motion tracking system captured performance data from participants' bilateral hand movements. Path length and suture time were segmented by each individual stitch placed to investigate changes to psychomotor performance with subsequent stitch placements. Repeated measures analysis of variance was used to evaluate for main effects of stitch order on path length and suture time and interactions between stitch order, material, and experience. RESULTS: When participants sutured the tissue paper, they changed their procedure time (F(4,44) = 5.14, P = 0.017) and path length (F(4,44) = 4.64, P = 0.003) in a linear fashion with the first stitch on the tissue paper having the longest procedure time and path length. Participants did not change their path lengths and procedure times when placing subsequent stitches in the foam (P = 0.910) and balloon materials (P = 0.769). CONCLUSIONS: This study demonstrates quantifiable real-time adaptation by participants to material characteristics during a suturing task. Participants improved their motion-based performance with each subsequent stitch placement indicating changes in psychomotor planning or performance. This adaptation did not occur with the less difficult tasks. Motion capture technology is a promising method for investigating surgical performance and how surgeons adapt to operative complexity.

Fc-Silent Anti-TIGIT Antibodies Potentiate Antitumor Immunity without Depleting Regulatory T Cells.

T-cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibitory motif domains (TIGIT) is an inhibitory receptor on immune cells that outcompetes an activating receptor, CD226, for shared ligands. Tumor-infiltrating lymphocytes express TIGIT and CD226 on regulatory T cells (Treg) and on CD8+ T cells with tumor-reactive or exhausted phenotypes, supporting the potential of therapeutically targeting TIGIT to enhance antitumor immunity. To optimize the efficacy of therapeutic antibodies against TIGIT, it is necessary to understand IgG Fc (Fcγ) receptor binding for therapeutic benefit. In this study, we showed that combining Fc-enabled (Fce) or Fc-silent (Fcs) anti-TIGIT with antiprogrammed cell death protein 1 in mice resulted in enhanced control of tumors by differential mechanisms: Fce anti-TIGIT promoted the depletion of intratumoral Treg, whereas Fcs anti-TIGIT did not. Despite leaving Treg numbers intact, Fcs anti-TIGIT potentiated the activation of tumor-specific exhausted CD8+ populations in a lymph node-dependent manner. Fce anti-TIGIT induced antibody-dependent cell-mediated cytotoxicity against human Treg in vitro, and significant decreases in Treg were measured in the peripheral blood of patients with phase I solid tumor cancer treated with Fce anti-TIGIT. In contrast, Fcs anti-TIGIT did not deplete human Treg in vitro and was associated with anecdotal objective clinical responses in two patients with phase I solid tumor cancer whose peripheral Treg frequencies remained stable on treatment. Collectively, these data provide evidence for pharmacologic activity and antitumor efficacy of anti-TIGIT antibodies lacking the ability to engage Fcγ receptor. SIGNIFICANCE: Fcs-silent anti-TIGIT antibodies enhance the activation of tumor-specific pre-exhausted T cells and promote antitumor efficacy without depleting T regulatory cells.

Molecular and histological correlates of cognitive decline across age in male C57BL/6J mice.

INTRODUCTION: Increasing age is the number one risk factor for developing cognitive decline and neurodegenerative disease. Aged humans and mice exhibit numerous molecular changes that contribute to a decline in cognitive function and increased risk of developing age-associated diseases. Here, we characterize multiple age-associated changes in male C57BL/6J mice to understand the translational utility of mouse aging. METHODS: Male C57BL/6J mice from various ages between 2 and 24 months of age were used to assess behavioral, as well as, histological and molecular changes across three modalities: neuronal, microgliosis/neuroinflammation, and the neurovascular unit (NVU). Additionally, a cohort of 4- and 22-month-old mice was used to assess blood-brain barrier (BBB) breakdown. Mice in this cohort were treated with a high, acute dose of lipopolysaccharide (LPS, 10 mg/kg) or saline control 6 h prior to sacrifice followed by tail vein injection of 0.4 kDa sodium fluorescein (100 mg/kg) 2 h later. RESULTS: Aged mice showed a decline in cognitive and motor abilities alongside decreased neurogenesis, proliferation, and synapse density. Further, neuroinflammation and circulating proinflammatory cytokines were increased in aged mice. Additionally, we found changes at the BBB, including increased T cell infiltration in multiple brain regions and an exacerbation in BBB leakiness following chemical insult with age. There were also a number of readouts that were unchanged with age and have limited utility as markers of aging in male C57BL/6J mice. CONCLUSIONS: Here we propose that these changes may be used as molecular and histological readouts that correspond to aging-related behavioral decline. These comprehensive findings, in the context of the published literature, are an important resource toward deepening our understanding of normal aging and provide an important tool for studying aging in mice.

Geolocated dataset of Chinese overseas development finance.

China is now the world's largest source of bilateral development finance and will likely continue to play a prominent role in sovereign lending through its multi-billion-dollar Belt and Road Initiative. This paper introduces major methodological enhancements in tracking this finance: the use of an original application programming interface (API) to gathers news in multiple languages; double-verification of every record to ensure every finance commitment has been formalized; and visual geo-location to trace the precise footprint of every project. The resulting dataset enables economic, environmental, and social analyses with high-precision spatial accuracy, as well as spatiotemporal monitoring by project stakeholders and enhanced planning by project managers. It covers the years 2008-2019 to enable analysis before and after the announcement of the Belt and Road Initiative. It includes 862 finance commitments, 669 of which have geographic location, to 94 countries across the world.

Risks to global biodiversity and Indigenous lands from China's overseas development finance.

China has become one of the world's largest lenders in overseas development finance. Development projects, such as roads, railways and power plants, often drive biodiversity loss and infringe on Indigenous lands, yet the risks implicit in China's overseas development finance are poorly understood. Here we examine the extent to which projects financed by China's policy banks between 2008 and 2019 occur within and adjacent to areas where large-scale investment can present considerable risks to biodiversity and Indigenous peoples. Further, we compare these risks with those posed by similar projects financed by the World Bank, previously the world's largest source of development finance. We found that 63% of China-financed projects overlap with critical habitats, protected areas or Indigenous lands, with up to 24% of the world's threatened birds, mammals, reptiles and amphibians potentially impacted by the projects. Hotspots of the risks are primarily distributed in northern sub-Saharan Africa, Southeast Asia and parts of South America. Overall, China's development projects pose greater risks than those of the World Bank, particularly within the energy sector. These results provide an important global outlook of socio-ecological risks that can guide strategies for greening China's development finance around the world.

Safety and tolerability of GRF6019 in mild-to-moderate Alzheimer's disease dementia.

INTRODUCTION: This phase 2 trial evaluated the safety, tolerability, and feasibility of repeated infusions of the plasma fraction GRF6019 in mild-to-moderate Alzheimer's disease. METHODS: In this randomized, double-blind, dose-comparison trial, 47 patients were randomized 1:1 to receive daily infusions of 100 mL (n = 24) or 250 mL (n = 23) of GRF6019 for 5 consecutive days over two dosing periods separated by a treatment-free interval of 3 months. RESULTS: The mean (standard deviation [SD]) age of the enrolled patients was 74.3 (6.9), and 62% were women. Most adverse events (55%) were mild, with no clinically significant differences in safety or tolerability between the two dose levels. The mean (SD) baseline Mini-Mental State Examination score was 20.6 (3.7) in the 100 mL group and 19.6 (3.7) in the 250 mL group; at 24 weeks, the within-patient mean change from baseline was -1.0 points (95% confidence interval [CI], -3.1 to 1.1) in the 100 mL group and +1.5 points (95% CI, -0.4 to 3.3) in the 250 mL group. The within-patient mean change from baseline on the Alzheimer's Disease Assessment Scale-Cognitive subscale was -0.4 points (95% CI, -2.9 to 2.2) in the 100 mL group, while in the 250 mL group it was -0.9 points (95% CI, -3.0 to 1.2). The within-patient mean change from baseline on the Alzheimer's Disease Cooperative Study-Activities of Daily Living was -0.7 points in the 100 mL group (95% CI, -4.3 to 3.0) and -1.3 points (95% CI, -3.4 to 0.7) in the 250 mL group. The mean change from baseline on the Category Fluency Test, Clinical Dementia Rating Scale-Sum of Boxes, Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change, and Neuropsychiatric Inventory Questionnaire was similar for both treatment groups and did not show any worsening. DISCUSSION: GRF6019 was safe and well tolerated, and patients experienced no cognitive decline and minimal functional decline. These results support further development of GRF6019.

Bottom-up and top-down processes in emotion generation: common and distinct neural mechanisms.

Emotions are generally thought to arise through the interaction of bottom-up and top-down processes. However, prior work has not delineated their relative contributions. In a sample of 20 females, we used functional magnetic resonance imaging to compare the neural correlates of negative emotions generated by the bottom-up perception of aversive images and by the top-down interpretation of neutral images as aversive. We found that (a) both types of responses activated the amygdala, although bottom-up responses did so more strongly; (b) bottom-up responses activated systems for attending to and encoding perceptual and affective stimulus properties, whereas top-down responses activated prefrontal regions that represent high-level cognitive interpretations; and (c) self-reported affect correlated with activity in the amygdala during bottom-up responding and with activity in the medial prefrontal cortex during top-down responding. These findings provide a neural foundation for emotion theories that posit multiple kinds of appraisal processes and help to clarify mechanisms underlying clinically relevant forms of emotion dysregulation.

Cognitive and neural development of individuated self-representation in children.

Processing the self-relevance of information facilitates recall. Similarly, processing close-other-related information facilitates recall to a lesser degree than processing self-relevant information. This memory advantage may be viewed as an index of the degree to which the representation of self is differentiated from representations of close others. To test developmental hypotheses concerning the self, this study examined the relation of memory for self- and mother-referentially processed information in participants age 7-13 years (Experiment 1: N = 37; Experiment 2: N = 14). Memory for words encoded with reference to oneself increases with age, relative to memory for words encoded with reference to one's mother. When used as an individual difference measure, the difference in self versus mother memory correlates with regions of the rostral anterior cingulate associated with affective salience.

Cross-sectional associations between [18F]GTP1 tau PET and cognition in Alzheimer's disease.

The regional relationships between tau positron emission tomography (PET) imaging and cognitive impairment in Alzheimer's disease (AD) remain uncertain. We examined cross-sectional associations between cognitive performance, cerebral uptake of the novel tau PET tracer [18F]GTP1, and other neuroimaging indices ([18F]florbetapir amyloid PET, magnetic resonance imaging) in 71 participants with normal cognition, prodromal AD, or AD dementia. Greater [18F]GTP1 uptake was seen with increasing clinical severity and correlated with poorer cognition. [18F]GTP1 uptake and cortical volume (but not [18F]florbetapir uptake) were independently associated with cognitive performance, particularly within the temporal lobe. Delayed memory was more specifically associated with temporal [18F]GTP1 uptake; other domains correlated with a broader range of regional [18F]GTP1 uptake. These data confirm that [18F]GTP1 tau PET uptake significantly correlates with cognitive performance in AD, but regional correlations between performance in non-memory cognitive domains were less specific than reported by tau PET imaging studies that included participants with atypical focal cortical AD syndromes. Tau PET imaging may have utility as a surrogate biomarker for clinical AD progression in therapeutic trials of disease-modifying interventions.

All in the mind's eye? Anger rumination and reappraisal.

Research on rumination has demonstrated that compared with distraction, rumination intensifies and prolongs negative emotion. However, rumination and distraction differ both in what one thinks about and how one thinks about it. Do the negative outcomes of rumination result from how people think about negative events or simply that they think about them at all? To address this question, participants in 2 studies recalled a recent anger-provoking event and then thought about it in 1 of 2 ways: by ruminating or by reappraising. The authors examined the impact of these strategies on subsequent ratings of anger experience (Study 1) as well as on perseverative thinking and physiological responding over time (Study 2). Relative to reappraisal, rumination led to greater anger experience, more cognitive perseveration, and greater sympathetic nervous system activation. These findings provide compelling new evidence that how one thinks about an emotional event can shape the emotional response one has.

The right to vacation: an international perspective.

This report reviews international vacation and holiday laws and finds that the United States is the only advanced economy that does not guarantee its workers any paid vacation or holidays. As a result, one in four U.S. workers do not receive any paid vacation or paid holidays. The lack of paid vacation and paid holidays in the United States is particularly acute for lower-wage and part-time workers, and for employees of small businesses. This report also includes a comparative appendix with information on paid leave and holiday laws in Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, and the United Kingdom.

Does repressive coping promote resilience? Affective-autonomic response discrepancy during bereavement.

Traditional theories of coping emphasize the value of attending to and expressing negative emotion while recovering from traumatic life events. However, recent evidence suggests that the tendency to direct attention away from negative affective experience (i.e., repressive coping) may promote resilience following extremely aversive events (e.g., the death of a spouse). The current study extends this line of investigation by showing that both bereaved and nonbereaved individuals who exhibited repressive coping behavior--as measured by the discrepancy between affective experience and sympathetic nervous system response--had fewer symptoms of psychopathology, experienced fewer health problems and somatic complaints, and were rated as better adjusted by close friends than those who did not exhibit repressive coping. Results are discussed in terms of recent developments in cognitive and neuroimaging research suggesting that repressive coping may serve a protective function.

Research Residents' perceptions of skill decay: Effects of repeated skills assessments and scenario difficulty.

INTRODUCTION: Skills decay is a known risk for surgical residents who have dedicated research time. We hypothesize that simulation-based assessments will reveal significant differences in perceived skill decay when assessing a variety of clinical scenarios in a longitudinal fashion. METHODS: Residents (N = 46; Returning: n = 16, New: n = 30) completed four simulated procedures: urinary catheterization, central line, bowel anastomosis, and laparoscopic ventral hernia repair. Perception surveys were administered pre- and post-simulation. RESULTS: Perceptions of skill decay and task difficulty were similar for both groups across three procedures pre- and post-simulation. Due to a simulation modification, new residents were more confident in urinary catheterization than returning residents (F(1,4) = 11.44, p = 0.002). In addition, when assessing expectations for skill reduction, returning residents perceived greater skill reduction upon reassessment when compared to first time residents (t(35) = 2.37, p = 0.023). CONCLUSION: Research residents may benefit from longitudinal skills assessments and a wider variety of simulation scenarios during their research years. TABLE OF CONTENTS SUMMARY: As part of a longitudinal study, we assessed research residents' confidence, perceptions of task difficulty and surgical skill reduction. Residents completed surveys pre- and post-experience with four simulated procedures: urinary catheterization, subclavian central line insertion, bowel anastomosis, and laparoscopic ventral hernia repair. Returning residents perceived greater skill reduction upon reassessment when compared to residents participating for the first time. In addition, modification of the clinical scenarios affected perceptions of skills decay.

Do errors and critical events relate to hernia repair outcomes?

BACKGROUND: The study aimed to validate an error checklist for simulated laparoscopic ventral hernia (LVH) repair procedures. We hypothesize that residents' errors can be assessed with a structured checklist and the results will correlate significantly with procedural outcomes. METHODS: Senior residents' (N = 7) performance on a LVH simulator were video-recorded and analyzed using a human error checklist. Junior residents (N = 38) performed two steps of the same simulated LVH procedure. Performance was evaluated using the error checklist and repair quality scores. RESULTS: There were no significant differences between senior and junior residents' checklist errors (p > 0.1). Junior residents' errors correlated with hernia repair quality (p = 0.05). CONCLUSIONS: The newly developed assessment tool showed significant correlations between performance errors, critical events, and hernia repair quality. These results provide validity evidence for the use of errors in performance assessments. SUMMARY: This study validated an error checklist for simulated laparoscopic ventral hernia (LVH) repair procedures. The checklist was designed based on errors committed by chief surgery residents during LVH repairs. In a separate data collection, junior residents were evaluated using the checklist. Hernia repair quality was also assessed. Errors significantly correlated with hernia repair quality (p = 0.05).

Mitochondrial DNA Profiling of Illegal Tortoiseshell Products Derived from Hawksbill Sea Turtles.

The hawksbill sea turtle (Eretmochelys imbricata) is a highly endangered species, commonly poached for its ornate shell. "Tortoiseshell" products made from the shell are widely, although illegally, available in many countries. Hawksbills have a circumglobal distribution; thus, determining their origin is difficult, although genetic differences exist geographically. In the research presented, a procedure was developed to extract and amplify mitochondrial DNA from tortoiseshell items, in an effort to better understand where the species is being poached. Confiscated tortoiseshell items were obtained from the U.S. Fish and Wildlife Service, and DNA from 56 of them was analyzed. Multiple mitochondrial haplotypes were identified, including five not previously reported. Only one tortoiseshell item proved to be of Atlantic origin, while all others corresponded to genetic stocks in the Indo-Pacific region. The developed methodology allows for unique, and previously unattainable, genetic information on the illegal poaching of sea turtles for the decorative tortoiseshell trade.