"I Came up Short on the Academic Ladder": A Grounded Theory Study of Careerism in Academic Surgery.

OBJECTIVE: This study aims to explore the definition of career success in academic surgery. BACKGROUND: Career success in academic surgery is frequently defined as the achievement of a specific title, from full professor to department chair. This type of definition is convenient and established but potentially incomplete. The business literature has a more nuanced view of the relationship between titles and success, but this relationship has not been studied in medicine. METHODS: Semi-structured interviews were conducted from May to November 2020. Data were analyzed in an iterative fashion using grounded theory methodology to develop a conceptual model. RESULTS: We conducted 26 semi-structured interviews with practicing surgeons differing in years of experience; 12 (46%) participants were female, mean age of 48. Participants included 5 chairs of surgery, 6 division chiefs, and 7 past or current presidents of national societies. Four themes emerged on the importance of titles: Some study participants reported that (1) titles are a barometer of success; others argued that (2) titles are not a sufficient metric to define success; (3) titles are a means to an end; and (4) there is a desire to achieve the title of a respected mentor. CONCLUSIONS: As the definition of career success in academic surgery changes to encompass a broader range of interests and ambitions, the traditional markers of success must come into review. Academic surgeons see the value of titles as a marker of success and as a means to achieving other goals, but overwhelmingly our interviewees felt that titles were a double-edged sword and that a more inclusive definition of academic success was needed.

"The Story I Will Never Forget": Critical Incident Narratives in Surgical Residency.

OBJECTIVE: We sought to better understand what defines a critical incident experience for the surgical trainee. SUMMARY BACKGROUND DATA: Critical incidents are formative moments stamped indelibly on one's memory that shape professional identity. The critical incident technique-using participants' narratives to identify patterns and learn from their perceptions-has been explored in some healthcare settings, but there has been no inquiry within surgery. METHODS: Surgical residents at 5 residency programs (1 community, 1 university-affiliated, 3 university) were surveyed using an online questionnaire from November to December 2020. Convenience sampling was used to identify the study population. Participants were invited to write about formative, impactful experiences in training. Interpretive description was the qualitative methodology used to locate information, analyze, and record patterns in the data. Individual responses were categorized and assessed for overlying themes. RESULTS: Overall, 28 narratives were collected from surgery residents in 3 specialties (general surgery, plastic surgery, and urology), with postgraduate year representation of post-graduate years 1 to 6. Respondents were 40% female. Nineteen of the narratives reported a negative experience. Four themes were identified from responses: 1) growth through personal self-reflection, 2) difficult interpersonal interactions, 3) positive team dynamics as a psychological safety net, and 4) supportive program cultures that promote learning. CONCLUSIONS: Critical incident narratives among surgical residents indicate that unforgettable and formative experiences-both positive and negative- occur in 4 domains: within the individual, within a relationship, among a team, and within a program. Further exploring these domains in surgical training will inform optimal educational programming to support trainee development and wellbeing.

Video is better: why aren't we using it? A mixed-methods study of the barriers to routine procedural video recording and case review.

INTRODUCTION: Video-based case review for minimally invasive surgery is immensely valuable for education and quality improvement. Video review can improve technical performance, shorten the learning curve, disseminate new procedures, and improve learner satisfaction. Despite these advantages, it is underutilized in many institutions. So far, research has focused on the benefits of video, and there is relatively little information on barriers to routine utilization. METHODS: A 36-question survey was developed on video-based case review and distributed to the SAGES email list. The survey included closed and open-ended questions. Numeric responses and Likert scales were compared with t-test; open-ended responses were reviewed qualitatively through rapid thematic analysis to identify themes and sub-themes. RESULTS: 642 people responded to the survey for a response rate of 11%. 584 (91%) thought video would improve the quality of educational conferences. 435 qualitative responses on the value of video were analyzed, and benefits included (1) improved understanding, (2) increased objectivity, (3) better teaching, and (4) better audience engagement. Qualitative comments regarding specific barriers to recording and editing case video identified challenges at all stages of the process, from (1) the decision to record a case, (2) starting the recording in the OR, (3) transferring and storing files, and (4) editing the file. Each step had its own specific challenges. CONCLUSION: Minimally invasive surgeons want to increase their utilization of video-based case review, but there are multiple practical challenges to overcome. Understanding these barriers is essential in order to increase use of video for education and quality improvement.

Quantification of gastric sleeve stenosis using endoscopic parameters and image analysis.

BACKGROUND AND AIMS: Sleeve gastrectomy has quickly become the most commonly performed bariatric surgery. In light of its increasing popularity, the prevalence of gastric sleeve stenosis (GSS) continues to rise. Management with serial pneumatic dilation is highly successful but underused because of a lack of quantitative diagnostic criteria. We aimed to develop quantifiable endoscopic criteria to characterize GSS based on the (1) ratio of narrowest to widest gastric lumen diameter, (2) endoscope angulation/trajectory required for passage, and (3) presence of bilious fluid pooling in the proximal sleeve and compare it with endoluminal functional lumen imaging probe (EndoFLIP) diameter and distensibility indices (DIs) and endoscopic documentation of gastric lumen morphology. METHODS: We retrospectively reviewed a prospectively maintained database of patients undergoing endoscopy to assess for GSS. Endoscopic images were reviewed in a blinded fashion by 2 bariatric endoscopists. The narrowest and widest part of the gastric lumen diameters were noted on each image, in addition to a hypothetical trajectory required for endoscope passage. Using image processing software, we calculated the the ratio of diameters (ie, narrowest divided by widest) and angle of endoscope trajectory. The presence of bilious fluid pooling in the proximal gastric lumen was noted. These values were then compared with EndoFLIP parameters and endoscopic documentation of gastric lumen morphology. RESULTS: Thirty patients met inclusion criteria, and 26 (87%) were found to have a stenosis on endoscopy. Of those, 9 (35%) were characterized as mild, 11 (42%) as moderate, and 6 (23%) as severe. There was no difference in demographic information between patients with and without stenosis. In patients with stenosis, mean EndoFLIP diameters and DIs were 12.9 ± 3.9 mm and 11.0 ± 6.8 mm2/mm Hg, respectively. In patients without stenosis, mean EndoFLIP diameters and DIs were 19.9 ± 2.9 mm and 21.5 ± 1.0 mm2/mm Hg, respectively. Patients with stenosis had significantly lower diameter ratios compared with those without stenosis (.27 ± .14 vs .48 ± .77, P = .01). Diameter ratios were also inversely related to severity of sleeve stenosis (ß = -.08, P = .01). Patients with stenosis were also more likely to have fluid pooling (96.2% vs 25%, P < .001). There was no significant difference in the trajectory of endoscope passage between the 2 groups. CONCLUSIONS: Endoscopic criteria for diagnosis of GSS are lacking. Our data suggest the ratio between the narrowest and widest gastric lumen diameters and presence of pooled fluid is associated with diagnosis of stenosis by EndoFLIP and gastric lumen morphology. Future studies to validate these criteria are needed.

Minimally invasive options for gastrointestinal stromal tumors of the stomach.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors, most commonly arising in the stomach. Surgical resection remains the mainstay of cure, and can often be accomplished laparoscopically. Tumor size and location guide selection of appropriate resection technique. METHODS: A retrospective review of all patients undergoing surgery at a single academic center between 2000 and 2018. Comparisons and descriptive statistics performed using student's t test and χ2 test. RESULTS: 77 patients underwent resection for gastric GIST, 53 (68%) laparoscopic. Patients undergoing open operations had significantly larger tumors (4 cm vs 7 cm, p < 0.001). Operative time was not significantly different between the two groups (117 min vs 104 min, p = 0.26). Median length of stay was significantly shorter for laparoscopic resection, and postoperative complication rate was lower. A review of the operative notes revealed four types of resection: non-anatomic stapled wedge resection, resection of a full-thickness "disk" of stomach around the tumor with primary closure, formal partial gastrectomy with reconstruction, and laparoscopic transgastric (endoluminal) resection. CONCLUSION: Non-anatomic resection (wedge or disk) is most feasible for tumors on the greater curve or gastric body, far enough from the pylorus and gastroesophageal junction to avoid narrowing inflow or outflow. A partial gastrectomy may be required for large tumors or those encroaching on the esophagus or pylorus. For small intraluminal tumors, a laparoscopic transgastric approach is ideal. This review of the technical details of each type of resection can aid in selecting the ideal approach for difficult tumors.

Peripheral Nerve Blocks and Immediate Postoperative Recovery: A Single-Institution Survey of Perianesthesia Nurses' Preferences and Opinions.

PURPOSE: To ascertain the preferences of perianesthesia nurses regarding peripheral nerve blocks (PNBs) and their impact on patient recovery after total joint replacement (TJR). DESIGN: Survey of perianesthesia nurses at a single medical center. METHODS: Fifty-nine perianesthesia nurses completed a 23-question survey on PNBs for TJR. FINDINGS: Most agreed PNBs improved patients' pain after knee, hip, and shoulder TJR (35 [92.1%], 35 [92.1%], and 34 [91.9%], respectively). Most felt lower extremity PNBs increased risk of falling (26 [70.3%]), whereas 7 of 35 (20.0%) felt patients fell more after spinal anesthesia than after general anesthesia. Respondents preferred a block to opioid-based analgesia if they were to have lower extremity TJR or total shoulder replacement (100% [30/30 and 33/33]). CONCLUSIONS: The perianesthesia nurses surveyed felt PNBs improved pain control and patient recovery despite a perceived risk of falling for lower extremity TJR, and they preferred PNB when considering TJR surgery for themselves.

A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication.

BACKGROUND: Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction. OBJECTIVE: To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers. DESIGN: Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons. PARTICIPANTS: Twenty-two internal medicine residents in their second or third postgraduate year. INTERVENTION: An educational dinner describing the format and potential benefits of using the CPI. MAIN MEASURES: Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians. KEY RESULTS: All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups. CONCLUSIONS: Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

Pilot evaluation of the Computer-Based Assessment for Sampling Personal Characteristics test.

BACKGROUND: High attrition rates hint at deficiencies in the resident selection process. The evaluation of personal characteristics representative of success is difficult. Here, we evaluate a novel tool for assessing personal characteristics. MATERIALS AND METHODS: To evaluate feasibility, we used an anonymous voluntary survey questionnaire offered to study participants before and after contact with the CASPer test. To evaluate the CASPer test as a predictor of success, we compared CASPer test assessments of personal characteristics versus traditional faculty assessment of personal characteristics with applicant rank list position. RESULTS: All applicants (n = 77) attending an in-person interview for general surgery residency, and all faculty interviewers (n = 34) who reviewed these applications were invited to participate. Among applicants, 84.4% of respondents (65 of 77) reported that a requirement to complete the CASPer test would have no bearing or would make them more likely to apply to the program (mean = 3.30, standard deviation = 0.96). Among the faculty, 62.5% respondents (10 of 16) reported that the same condition would have no bearing or would make applicants more likely to apply to the program (mean = 3.19, standard deviation = 1.33). The Spearman's rank-order correlation coefficients for the relationships between traditional faculty assessment of personal characteristics and applicant rank list position, and novel CASPer assessment of personal characteristics and applicant rank list position, were -0.45 (P = 0.033) and -0.41 (P = 0.055), respectively. CONCLUSIONS: The CASPer test may be feasibly implemented as component of the resident selection process, with the potential to predict applicant rank list position and improve the general surgery resident selection process.

Who Orders a Head CT?: Perceptions of the Cirrhotic Bleeding Risk in an International, Multispecialty Survey Study.

OBJECTIVE: Traditional coagulopathic indices, including elevated international normalized ratio, do not correlate with bleeding risk in patients with cirrhosis. For this reason, head computed tomography (CT) has a low yield in cirrhotic patients with altered mental status and no trauma history. The initial diagnostic evaluation, however, is often made by nongastroenterologists influenced by the so-called "coagulopathy of cirrhosis." We sought to examine the prevalence, impact, and malleability of this perception in an international, multispecialty cohort. DESIGN: An electronic survey was distributed to internal medicine, surgery, emergency medicine, and gastroenterology physicians. Respondents were presented with a cirrhotic patient with hepatic encephalopathy, no history of trauma, and a nonfocal neurological examination. Respondents rated likelihood to order head CT at presentation, after obtaining labs [international normalized ratio (INR) 2.4 and platelets 59×10/µL], and finally after reading the results of a study demonstrating the low yield of head CT in this setting. RESULTS: In total, 1286 physicians from 6 countries, 84% from the United States. Of these, 62% were from internal medicine, 25% from emergency medicine, 8% from gastroenterology, and 5% from surgery. Totally, 47% of respondents were attending physicians. At each timepoint, emergency physicians were more likely, and gastroenterologists less likely, to scan than all other specialties (P<0.0001). Evidence on the low yield of head CT reduced likelihood to scan for all specialties. Qualitative analysis of open-ended comments confirmed that concern for "coagulopathy of cirrhosis" motivated CT orders. CONCLUSIONS: Perceptions regarding the coagulopathy of cirrhosis, which vary across specialties, impact clinical decision-making. Exposure to clinical evidence has the potential to change practice patterns.

Perioperative ketamine for acute postoperative analgesia: the Mayo Clinic-Florida experience.

Many common elective surgeries are associated with moderate-to-severe postoperative pain. These common surgeries include total knee and total hip arthroplasty, thoracotomy, and multilevel lumbar spine surgery. Unfortunately, many patients requiring these surgeries are already in moderate-to-severe pain, necessitating high doses of oral or transdermal opioids preoperatively. This is an established risk factor for difficult-to-control postoperative pain.(1,2) Opioid-sparing interventions are important elements in these patients to promote convalescence and reduce common opioid side effects such as constipation, confusion, pruritus, nausea, vomiting, and urinary retention. Potential interventions to reduce postoperative pain can include nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, and even invasive therapies such as epidural or peripheral nerve blockade. Ketamine is a well-known anesthetic agent that has opioid-sparing analgesic properties, is noninvasive, and in analgesic doses, has few contraindications. This article will review the basic science behind ketamine, some of the evidence supporting its perioperative use, and the logistics of how the Department of Anesthesia at Mayo Clinic in Jacksonville, Florida rolled out a hospital-wide ketamine infusion protocol.

Patients With Systemic Reaction to Their Hernia Mesh: An Introduction to Mesh Implant Illness.

In our practice, we have noticed an increased number of patients requiring mesh removal due to a systemic reaction to their implant. We present our experience in diagnosing and treating a subpopulation of patients who require mesh removal due to a possible mesh implant illness (MII). All patients who underwent mesh removal for indication of mesh reaction were captured from a hernia database. Data extraction focused on the patients' predisposing medical conditions, presenting symptoms suggestive of mesh implant illness, types of implants to which reaction occurred, and postoperative outcome after mesh removal. Over almost 7 years, 165 patients had mesh removed. Indication for mesh removal was probable MII in 28 (17%). Most were in females (60%), average age was 46 years, with average pre-operative pain score 5.4/10. All patients underwent complete mesh removal. Sixteen (57%) required tissue repair of their hernia; 4 (14%) had hybrid mesh implanted. Nineteen (68%) had improvement and/or resolution of their MII symptoms within the first month after removal. We present insight into a unique but rising incidence of patients who suffer from systemic reaction following mesh implantation. Predisposing factors include female sex, history of autoimmune disorder, and multiple medical and environmental allergies and sensitivities. Presenting symptoms included spontaneous rashes, erythema and edema over the area of implant, arthralgia, headaches, and chronic fatigue. Long-term follow up after mesh removal confirmed resolution of symptoms after mesh removal. We hope this provides greater attention to patients who present with vague, non-specific but debilitating symptoms after mesh implantation.

Pneumatic Balloon Dilation of Gastric Sleeve Stenosis Is Not Associated with Weight Regain.

BACKGROUND: Gastric sleeve stenosis (GSS) occurs in up to 4% of patients after laparoscopic sleeve gastrectomy (LSG). Typical symptoms include reflux, abdominal pain, dysphagia, and regurgitation. Serial pneumatic balloon dilation (PBD) is a successful treatment in many cases obviating the need for revisional surgery, but the potential for weight regain is unknown. The aim of the current study was to assess weight trends following serial pneumatic dilation for GSS. METHODS: Retrospective analysis of a prospectively maintained database of patients undergoing serial PBD for GSS at one institution. Primary outcome was change in BMI before and after serial PBD. Secondary outcomes included complication rates and need for revisional surgery. Sub-group analyses were performed to determine the relationship of patient and procedural factors to BMI after PBD. RESULTS: Forty-four patients met inclusion criteria, 34 (84.1%) women. Mean age was 46.7 (SD 11.9). Mean pre-sleeve BMI was 47.8 (SD 9.2), and mean BMI prior to first dilation was 34.2 (SD 6.8). Median follow-up was 395 days (range 48-571). Mean BMI at time of last follow up was 33.7 (SD 6.7). There was no statistical difference in BMI pre- or post-PBD (p 0.980). The lowest 10th and highest 90th BMI percentile trended toward a higher and lower BMI after PBD, respectively, though not significant. DISCUSSION: As the prevalence of sleeve gastrectomy continues to rise, an increasing number of patients will require treatment for GSS. Stenosis is effectively treated with serial PBD in most patients without any impact on weight gain, making this an effective and appealing option for many patients.

Quantifying Healthcare Utilization and Delay in the Treatment of Gastric Stenosis Following Sleeve Gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is the most common bariatric procedure performed. The incidence of gastric sleeve stenosis (GSS) is up to 4%, with a rising prevalence given increasing popularity of this surgery. GSS is best treated with pneumatic balloon dilation (PBD), but the diagnosis is not always straightforward, oftentimes leading to an extensive diagnostic workup. The aims of the current study were to quantify delay to treatment and overall healthcare utilization during this delay in patients with GSS following SG. METHODS: This was a retrospective review of a prospectively collected database including patients with SG diagnosed with GSS between October 2017 and September 2020. The primary outcome was time between symptom development and treatment with PBD. Secondary outcomes included total healthcare utilization as reflected by the number and charges of imaging and emergency room (ER) visits. RESULTS: Forty-five patients were included in the analysis; 37 (82%) were female. The mean (± SD) time to treatment was 755 (± 713) days. The probability of receiving treatment at 1, 2, and 3 years was 37%, 62%, and 76%, respectively. The mean (± SD) abdominal CT scans, radiographs, and UGIS between symptoms and PBD were 1.3 ± 2.0, 1.2 ± 1.6, and 1.2 ± 1.0, respectively. The mean number of ER visits was 1.9 ± 2.5 (range 0-8). The average number of diagnostic non-therapeutic upper endoscopies was 1.6 ± 1.5. The mean (± SD) total charges were $16,473 ± 15,173. CONCLUSION: Patients who develop GSS following SG experience significant delay in diagnosis and management, reflected by multiple imaging studies, emergency department visits, and non-therapeutic procedures.

Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae. OBJECTIVE: This study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG. SETTING: Single bariatric center, United States. METHODS: Analysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI). RESULTS: A total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P < .001) and at long-term follow-up (n = 37; 90%) (P ≤ .001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P < .001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P < .001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P < .001). These 12 patients were found to exhibit a significantly (P = .005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB. CONCLUSION: Conversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion.

How Do Programs Measure Resident Performance? A Multi-Institutional Inventory of General Surgery Assessments.

OBJECTIVE: To perform an inventory of assessment tools in use at surgical residency programs and their alignment with the Milestone Competencies. DESIGN: We conducted an inventory of all assessment tools from a sample of general surgery training programs participating in a multi-center study of resident operative development in the United States. Each instrument was categorized using a data extraction tool designed to identify criteria for effective assessment in competency based education and according to which Milestone Competency was being evaluated. Tabulations of each category were then analyzed using descriptive statistics. Interviews with program directors and assessment coordinators were conducted to understand each instrument's intended use within each program. SETTING: Multi-institutional review of general surgery assessment programs. PARTICIPANTS: We identified assessment tools used by 10 general surgery programs during the 2019 to 2020 academic year. Programs were selected from a cohort already participating in a separate research study of resident operative development in the United States. RESULTS: We identified 42 unique assessment tools used. Each program used an average of 7.2 (range 4-13) unique assessment instruments to measure performance, of which only 5 (11.9%) were used by at least 1 other program in our sample. Of all assessments, 59.5% were used monthly or less frequently. The majority (66.7%) of instruments were retrospective global assessments, rather than discrete observed performances. There were 4 (9.5%) instruments with established reliability or validity evidence. Across programs there was also significant variation in the volume of assessment used to evaluate residents, with the median total number of evaluations/trainee across all Milestone Competencies being 217 (IQR 78) per year. Patient care was the most frequently evaluated Milestone Competency. CONCLUSIONS: General surgical assessment systems predominantly employ non-standardized global assessment tools that lack reliability or validity evidence. This variability makes it challenging to interpret and compare competency standards across programs. A standardized assessment toolkit with established reliability and validity evidence would allow training programs to measure the competence of their trainees more uniformly and understand where improvements in our training system can be made.

Docosahexaenoic acid status in females of reproductive age with maple syrup urine disease.

Individuals with maple syrup urine disease (MSUD) have impaired metabolism of branched-chain amino acids (BCAA) valine, isoleucine, and leucine. Life-long dietary therapy is recommended to restrict BCAA intake and thus prevent poor neurological outcomes and death. To maintain adequate nutritional status, the majority of protein and nutrients are derived from synthetic BCAA-free medical foods with variable fatty acid content. Given the restrictive diet and the importance of omega-3 fatty acids, particularly docosahexaenoic acid (DHA), in neurological development, this study evaluated the dietary and fatty acid status of females of reproductive age with MSUD attending a metabolic camp. Healthy controls of similar age and sex were selected from existing normal laboratory data. Total lipid fatty acid concentration in plasma and erythrocytes was analyzed using gas chromatography-mass spectroscopy. Participants with MSUD had normal to increased concentrations of plasma and erythrocyte alpha linolenic acid (ALA) but significantly lower concentrations of plasma and erythrocyte docosahexaenoic acid (DHA) as percent of total lipid fatty acids compared with controls (plasma DHA: MSUD 1.03 +/- 0.35, controls 2.87 +/- 1.08; P = 0.001; erythrocyte DHA: MSUD 2.58 +/- 0.58, controls 3.66 +/- 0.80; P = 0.011). Dietary records reflected negligible or no DHA intake over the 3-day period prior to the blood draw (range 0-2 mg). These results suggest females of reproductive age with MSUD have lower blood DHA concentrations than age-matched controls. In addition, the presence of ALA in medical foods and the background diet may not counter the lack of preformed DHA in the diet. The implications of these results warrant further investigation.

Improving satisfaction with postoperative pain management for patients with persistent pain: a preoperative pain medicine consultation intervention.

PURPOSE: Preoperative pain medicine consultations with opioid-tolerant patients allow for an accurate medication history, patient involvement in the postoperative plan, and realistic goal setting. The purpose of this quality improvement project was to increase attendance at preoperative pain consultations, thereby increasing patient satisfaction. METHODS: Retrospective chart reviews identified patients who had a preoperative pain consultation ordered from May through July 2016. Patient interviews determined reasons for not attending appointments, involvement in goal setting, engagement in pain management planning, and satisfaction with postoperative pain management. RESULTS: Retrospective chart reviews and interviews were conducted after the intervention (May-July 2017). Scheduling changes increased attendance at preoperative pain consultations by 14 percentage points (50% vs 64%). Those who attended consultations were more involved in goal setting and decisions and were more satisfied. CONCLUSIONS: Preoperative pain consultations with opioid-tolerant patients can increase satisfaction through realistic goal setting and involvement in the pain management plan.

Knowing Your Team: Rapid Assessment of Residents and Fellows for Effective Horizontal Care Delivery in Emergency Events.

BACKGROUND: Horizontal care, in which clinicians assume roles outside of their usual responsibilities, is an important health care systems response to emergency situations. Allocating residents and fellows into skill-concordant clinical roles, however, is challenging. The most efficient method to accomplish graduate medical education (GME) assessment and deployment for horizontal care is not known. OBJECTIVE: We designed a categorization schema that can efficiently facilitate clinical and educational horizontal care delivery for trainees within a given institution. METHODS: In September 2019, as part of a general emergency response preparation, a 4-tiered system of trainee categorization was developed at one academic medical center. All residents and fellows were mapped to this system. This single institution model was disseminated to other institutions in 2020 as the COVID-19 pandemic began to affect hospitals nationally. In March 2020, a multi-institution collaborative launched the Trainee Pandemic Role Allocation Tool (TPRAT), which allows institutions to map institutional programs to COVID-19 roles within minutes. This was disseminated to other GME programs for use and refinement. RESULTS: The emergency response preparation plan was disseminated and selectively implemented with a positive response from the emergency preparedness team, program directors, and trainees. The TPRAT website was visited more than 100 times in the 2 weeks after its launch. Institutions suggested rapid refinements via webinars and e-mails, and we developed an online user's manual. CONCLUSIONS: This tool to assess and deploy trainees horizontally during emergency situations appears feasible and scalable to other GME institutions.

What Is the Best Operation for Proximal Gastric Cancer and Distal Esophageal Cancer?

Cancer of the gastroesophageal junction (GEJ) is increasing in incidence, likely as a result of rising obesity and gastroesophageal reflux disease rates. The tumors that arise here share features of esophageal and gastric cancer, and are classified based on their location in relationship to the GEJ. The definition of the GEJ itself, as well as optimal resection strategy, extent of lymph node dissection, resection margin length, and reconstruction methods are still very much a subject of debate. This article summarizes the available evidence on this topic, and highlights specific areas for further research.