Assessment of medical student burnout: toward an implicit measure to address current issues.

The feasibility of implicitly assessing medical student burnout was explored, using the Implicit Relational Assessment Procedure (IRAP), to measure longitudinal student burnout over the first two years of medical school and directly comparing it with an existing explicit measure of burnout (Maslach Burnout Inventory; MBI). Three successive cohorts of medical students completed both implicit and explicit measures of burnout at several time points during their first two years of medical school. Both assessments were conducted via the internet within a one-week period during the first week of medical school, the end of the first year of medical school, and the end of the second year, though not all cohorts were able to complete the assessments at all time points. Mixed linear models were used to compare the two measures directly, as well as to evaluate changes over time in each measure separately. Minimal correspondence was observed between the implicit and explicit measures of burnout on a within-subject basis. However, when analyzed separately, all subscales of both measures detected significant change over time in the direction of greater levels of burnout, particularly during the first year of medical school. These results provide preliminary evidence the IRAP is able to assess implicit attitudes related to burnout among medical students, though additional research is needed. The IRAP detected consistent improvements in positive implicit attitudes toward medical training during students' second year of medical school, which was not detected by the MBI. Possible implications of these findings are discussed.

Identifying the Protein Interactions of the Cytosolic Iron-Sulfur Cluster Targeting Complex Essential for Its Assembly and Recognition of Apo-Targets.

The cytosolic iron-sulfur cluster assembly (CIA) system assembles iron-sulfur (FeS) cluster cofactors and inserts them into >20 apoprotein targets residing in the cytosol and nucleus. Three CIA proteins, called Cia1, Cia2, and Met18 in yeast, form the targeting complex responsible for apo-target recognition. There is little information about the structure of this complex or its mechanism of CIA substrate recognition. Herein, we exploit affinity co-purification and size exclusion chromatography to determine the subunit connectivity and stoichiometry of the CIA targeting complex. We conclude that Cia2 is the organizing center of the targeting complex, which contains one Met18, two Cia1, and four Cia2 polypeptides. To probe target recognition specificity, we utilize the CIA substrates Leu1 and Rad3 as well as the Escherichia coli FeS-binding transcription factor FNR (fumerate nitrate reductase). We demonstrate that both of the yeast CIA substrates are recognized, whereas the bacterial protein is not. Thus, while the targeting complex exhibits flexible target recognition in vitro, it cannot promiscuously recognize any FeS protein. Additionally, we demonstrate that the full CIA targeting complex is required to stably bind Leu1 in vitro, whereas the Met18-Cia2 subcomplex is sufficient to recognize Rad3. Together, these results allow us to propose a unifying model for the architecture of this highly conserved complex and demonstrate what component or subcomplexes are vital for target identification.

Development of an Anisotropic Hyperelastic Material Model for Porcine Colorectal Tissues.

Many colonic surgeries include colorectal anastomoses whose leaks may be life-threatening, affecting thousands of patients annually. Various studies propose that mechanical interaction between the staples and neighboring tissues may play an important role in anastomotic leakage. Therefore, understanding the mechanical behavior of colorectal tissue is essential to characterizing the reasons for this type of failure. So far, experimental data characterizing the mechanical properties of colorectal tissue have been few and inconsistent, which has significantly limited understanding their behavior. This research proposes an approach to developing an anisotropic hyperelastic material model for colorectal tissues based on uniaxial testing of freshly harvested porcine specimens, which were collected from several age- and weight-matched pigs. The specimens were extracted from the same colon tract of each pig along their circumferential and longitudinal orientations. We propose a constitutive model combining Yeoh isotropic hyperelastic material with fibers oriented in two directions to account for the hyperelastic and anisotropic nature of colorectal tissues. Experimental data were used to accurately determine the model's coefficients (circumferential, R2 = 0.9968; longitudinal, R2 = 0.9675). The results show that the proposed model can be incorporated into a finite element model that can simulate procedures such as colorectal anastomoses reliably.

Mirizzi syndrome: The Trojan horse of gallbladder disease.

Background: The incidence of Mirizzi Syndrome ranges from 0.05 to 5.7 % of patients who undergo cholecystectomy. The purpose of this study is to examine the preoperative workup and postoperative outcomes for patients diagnosed with Mirizzi Syndrome. Methods: Retrospective chart review was conducted between January 2018 and January 2022 at a single institution. All adult patients who underwent cholecystectomy were included. Results: 1628 patients underwent cholecystectomy of which 47 were diagnosed with Mirizzi Syndrome. The majority of patients had type 1 Mirizzi Syndrome. Preoperative studies were often nondiagnostic and 81 % of cases were diagnosed intraoperatively. 66 % of cases were performed laparoscopically, an open approach was required for type V Mirizzi Syndrome. The complication rate was 25 %; most commonly a bile leak requiring ERCP. Conclusion: Mirizzi syndrome is more common than previously expected and related to patient's ability to seek timely medical care. Most cases can be completed laparoscopically however there is a high rate of complications. Key message: This study presents an additional cohort of patients found to have Mirizzi syndrome and supports the hypothesis that it is difficult to diagnose preoperatively. Cases should be attempted laparoscopically but there remains a high complication rate.

Promoting Firearm Injury Prevention and Advocacy as Pediatric Surgeons: A Call to Action From the APSA/AAP Advocacy Committee.

Firearm injuries have become the leading cause of death among American children. Here we review the scope of the problem, and the pivotal role pediatric surgeons have in preventing pediatric firearm injury. Specific methods for screening and counseling are reviewed, as well as how to overcome barriers. Community and hospital resources as well as organizational efforts are discussed. Finally, a path for surgeon advocacy is outlined as is a call to action for the pediatric surgeon, as we are uniquely poised to identify pediatric patients and deliver timely interventions to reduce the impact of firearm violence. LEVEL OF EVIDENCE: Level IV.

Outcomes of Primary Tumor Excision do not Differ from Non-Resection Methods in Pediatric Mesenchymal Hamartoma of the Liver: A Rapid Systematic Review.

BACKGROUND: To conduct a rapid systematic review comparing the outcomes of primary tumor resection versus non-resection on patients with hepatic mesenchymal hamartoma. METHODS: We searched the Ovid MEDLINE, EMBASE, Scopus, PubMed, Web of Science, and Google Scholar databases from January 1, 2000 to March 31, 2022. Studies that described cases of hepatic mesenchymal hamartoma, including management and outcomes, were included. RESULTS: 62 articles met inclusion criteria with 95 cases in total. Patients were assigned to the primary tumor resection (n = 85) or non-resection (n = 10) cohort based on the described management. Similar rates of morbidity (17% vs 20%) and mortality (6 vs 10%) were identified between cohorts. There were no differences in sex, liver lobe involvement, or tumor size among study groups. CONCLUSIONS: Complete tumor resection should remain the gold standard for hepatic mesenchymal hamartomas when an adequate liver remnant exists. Reports of non-resected tumors demonstrating spontaneous regression or stability with watchful waiting have poor long term follow-up and have inadequate evidence of a true mesenchymal hamartoma diagnosis. LEVEL OF EVIDENCE: Level I.

Infectious Complications and Antibiotic Use in Gastroschisis.

Background: Gastroschisis is a challenging neonatal condition often with prolonged hospitalizations, need for parenteral nutrition, infectious complications, and can even result in death. Infection is reported to occur in up to two-thirds of patients with gastroschisis and is a strong risk factor for increased morbidity and mortality. Increased days with a central venous catheter, complex gastroschisis, and delayed abdominal wall closure have been consistently found to be associated with increased risk of infection, whereas sutureless gastroschisis closure has been associated with fewer infections. Although one of the most common complications of gastroschisis is infection, the use of antibiotic agents varies widely with variability in the literature to guide management. Antibiotic usage should be selective and short-term, especially in neonates with simple gastroschisis regardless of method for abdominal wall closure. Conclusions: Future initiatives should focus on development of evidence-based guidelines on the care of these patients with the goal of reducing variability and improve outcomes within and across institutions.

The Use of Vasopressors During Deceased Donor Pancreas Procurement Decreases the Risk of Pancreas Transplant Graft Failure.

OBJECTIVES: The objective of this study was to identify the effect of various vasopressors on pancreas graft failure and patient survival. METHODS: A retrospective analysis of the United Network for Organ Sharing database was performed between 2000 and 2019. Patient and graft survival rates were analyzed up to 5 years posttransplant. RESULTS: The data included 17,348 pancreas transplant recipients: 12,857 simultaneous pancreas-kidney, 1440 pancreas transplant alone, and 3051 pancreas-after-kidney transplant recipients. Use of dopamine during deceased donor procurement increased graft failure by 18% (hazard ratio [HR], 1.18; P < 0.001). Absence of vasopressor caused graft failure to rise by 8% (HR, 1.08; P = 0.09). Dopamine increased the mortality rate by 37% (HR, 1.37; P < 0.001) and the absence of vasopressor increased the mortality rate by 14% (HR, 1.14; P = 0.02). Phenylephrine and norepinephrine reduced the mortality rate by 10% (HR, 0.90; P = 0.05) and 11% (HR, 0.89; P = 0.10), respectively. CONCLUSIONS: The absence of vasopressor use or the use of dopamine is associated with a higher risk of both pancreas transplant graft failure and recipient mortality. The use of phenylephrine and norepinephrine reduces the risk of mortality. This information should guide deceased donor hemodynamic support management in anticipation of pancreas procurement for future transplantation.

Cornual abscess rupture: A rare etiology of acute abdomen.

Ruptured cornual abscess or pyometra can resemble other more common causes of acute abdomen, including appendicitis, diverticulitis, tubo-ovarian abscess, and perforated viscus. Despite its rarity, the diagnosis of ruptured pyometra should always be considered in females presenting with acute abdominal pain, particularly in the setting of a retained intrauterine device.