Do Attending Surgeons and Residents See Eye To Eye? An Evaluation of the Accreditation Council For Graduate Medical Education Milestones in General Surgery Residency.

OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited general surgery residencies to implement competency-based developmental outcomes in resident evaluations. Overall, 16 milestones are evaluated by a clinical competency committee (CCC). The milestones span 8 domains of surgical practice and 6 Accreditation Council for Graduate Medical Education clinical competencies. The highest level suggests preparedness for independent practice. Our objective was to compare self-assessments and committee evaluations within the milestone framework. STUDY DESIGN: All residents underwent semiannual evaluations from 2013 to 2015. Residents independently completed a self-assessment using the milestones. The CCC completed the milestones document using resident evaluations and consensus opinion of committee members. Assessment differences were calculated for each evaluation. A negative value indicated that the residents evaluated themselves at a lower level than the committee. Major assessment disparities were defined as >0.5 on a 4-point scale. SETTING: An independent academic medical center. PARTICIPANTS: General surgery residents. RESULTS: Overall, 20 residents participated; 7 were female. In total, 5 (7%) evaluations had a mean overall assessment difference >0.5, whereas 6 (8%) had a difference <-0.5. Residents evaluated themselves lower than the committee with a median assessment difference of -0.06 [-0.25 to 0.16] (p = 0.041). Evaluations were similar across surgical domains. Negative self-evaluations were more common for medical knowledge (-0.25 [-0.25 to 0.25], p = 0.025). Female residents had 2% positive and 13% negative major assessment disparity rates versus 10% positive and 9% negative rates among male residents. Postgraduate year III residents had 12% positive and 4% negative major disparity rates; all other years had higher negative than positive rates. CONCLUSIONS: Surgery residents within our program demonstrated adequate self-awareness, with most self-evaluations falling within a half level of the CCC report. This self-awareness was consistent across surgical domains and most clinical competencies. Residents perceived a lower level of medical knowledge than the CCC. Subgroup analysis revealed interesting trends in the effects of sex, postgraduate year level, and academic year timing, which will take additional study to fully delineate.

Is the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator applicable for breast cancer patients undergoing breast-conserving surgery?

BACKGROUND: We aimed to analyze the applicability of the National Surgical Quality Improvement Program (NSQIP) calculator to patients undergoing breast-conserving surgery. METHODS: A total of 287 consecutive patients treated with breast-conserving surgery from 2010 to 2012 were identified retrospectively. The risk calculator was applied to each patient to generate an individual risk profile. Risk calculations were then compared with actual outcomes. The performance of the risk calculator was evaluated using 2 metrics: the Brier score and c statistic. RESULTS: The NSQIP calculator performed adequately for all complications, with Brier scores less than .05. However, 37 patients (12.9%) returned to the operating room for oncologic indications. Twenty-nine patients (10.1%) had positive margins, whereas 8 patients (2.8%) returned due to an upgrade in diagnosis. CONCLUSIONS: When considering return to the operating room for oncologic management, the observed rate of 13.9% is significantly higher than the NSQIP prediction. This deviation must be addressed when using the NSQIP risk calculator model during preoperative risk discussion.

A reproducible porcine ePTFE arterial bypass model for neointimal hyperplasia.

BACKGROUND: Late failure of prosthetic vascular bypass grafting using expanded polytetrafluoroethylene (ePTFE) is secondary to the development of neointimal hyperplasia, most commonly at the distal anastomosis. To develop therapies that can improve upon current prosthetic vascular bypass grafting, a large animal model of prosthetic bypass grafting that results in reproducible neointimal hyperplasia is necessary. METHODS: We performed bilateral end-to-side carotid artery bypasses with 6 mm ePTFE in a porcine model (n = 11). We studied graft patency using magnetic resonance angiography (MRA, 3 wk), duplex ultrasonography (4 wk), and digital-subtraction contrast angiography (4 wk). Animals were sacrificed at 4 wk and morphometric analysis was performed. RESULTS: Of the 11 animals that underwent surgery, one pig died from respiratory compromise; of the remaining 10, graft patency was 90% at 4 wk. Peak systolic and end diastolic velocities were established for this model using ultrasonography. MRA, ultrasonography, and angiography confirmed graft patency and were complimentary tools to evaluate the grafts. Development of neointimal hyperplasia was reproducible at 4 wk in both the proximal and distal anastomoses (2.5 to 3 mm(2)) of the ePTFE bypass grafts. CONCLUSION: We developed a reproducible porcine ePTFE carotid artery bypass model for studying neointimal hyperplasia. Not only does this model allow for the manipulation and evaluation of potential therapies, but patency and neointimal hyperplasia can be easily evaluated by traditional means, such as MRA, ultrasonography, and angiography. This preclinical model is ideal for evaluation of novel therapies in vivo designed to inhibit neointimal hyperplasia following arterial reconstruction with prosthetic bypass grafting.

Beneficial effect of a short-acting NO donor for the prevention of neointimal hyperplasia.

Nitric oxide (NO)-based therapies effectively inhibit neointimal hyperplasia in animal models of arterial injury and bypass grafting, but are not available clinically. We created a simple, effective, locally applied NO-eluting therapy to prevent restenosis after vascular procedures. We investigated the efficacy of perivascular delivery of two distinctly different diazeniumdiolate NO donors, 1-[2-(carboxylato)pyrrolidin-1-yl]diazen-1-ium-1,2-diolate (PROLI/NO) (short half-life) and diazeniumdiolated poly(acrylonitrile) (PAN/NO) (long half-life), in powder or gel form (30% poloxamer 407), at inhibiting neointimal hyperplasia using the rat carotid artery injury model. Two weeks postinjury, all of the NO-eluting therapies successfully reduced neointimal hyperplasia. However, most dramatically, PROLI/NO powder reduced intimal area by 91.2% (p<0.05) versus injury alone. PROLI/NO powder was noted to reduce the medial area (40.2% vs injury alone, p<0.05), whereas other groups showed no such effect. Three days postinjury, each NO treatment group significantly reduced cellular proliferation. However, inflammatory markers revealed a distinct pattern: PAN/NO groups displayed increased leukocyte infiltration (p<0.05), whereas PROLI/NO groups displayed less macrophage infiltration (p<0.05). In conclusion, perivascular delivery of diazeniumdiolate NO donors in powder or gel form effectively inhibits neointimal hyperplasia. Application of short-acting PROLI/NO powder most effectively inhibited neointimal hyperplasia and inflammation and may represent a simple, clinically applicable NO-eluting therapy to prevent neointimal hyperplasia and restenosis after open vascular interventions.