Goals, Structure and Financing of Surgical Residency Training: A Subcommittee Report of the Blue Ribbon Committee II.

OBJECTIVE: As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes. SUMMARY BACKGROUND DATA: Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics and cardiovascular) and now entrustable professional activities (EPAs) as part of competency based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available. METHODS: Convened subcommittee discussions to determine needed focus for recommendations. RESULTS: Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students and residents in training. CONCLUSIONS: Changes in surgical training related to CBME offer opportunity for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training.

Iron rich glauconite sand as an efficient phosphate immobilising agent in river sediments.

The reductive dissolution of iron (Fe) (oxy)hydroxides in sediments releases phosphorus (P) to the overlying water and may lead to eutrophication. Glauconite sands (GS) are rich in Fe and may be used as readily available P sorbents. This study was set up to test effects of dose and type of GS on the P immobilisation in sediments under hypoxic conditions. Three different GS were amended to a P-rich river sediment at doses of 0% (control), 5% and 10% (weight fractions) and incubated with overlying water in batch laboratory conditions. Glutamate was added to the solution after 15 days to deplete any residual dissolved oxygen from the sediment-water interface. In the first 15 days, the P concentration in the overlying water peaked to 1.5 mg P L-1 at day 9 in the control and decreased to 0.9 mg P L-1 at lowest Fe-dose and to 0.03 mg P L-1 at the highest Fe-dose, the effects of GS type and dose were explained by the Fe dose. After 15 days, the added glutamate induced a second, and larger peak of P in the overlying water in sediment, that peak was lower in amended sediments but no GS dose or type related effects were found. This suggests that freshly precipitated P species at the sediment-water interface can be remobilised. This study highlights the potential for using this natural mineral as a cheap and easily available sediment remediation material, but its longevity under rare extreme conditions needs to be further investigated.

The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy.

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrRP/B <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmH2O depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmH2O] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B).

Overexpression of human Bcl-2 in syngeneic rat donor lungs preserves posttransplant function and reduces intragraft caspase activity and interleukin-1beta production.

BACKGROUND: A significant cause of primary graft failure in lung transplantation is ischemia-reperfusion (I/R). I/R injury generates proinflammatory cytokines, such as interleukin (IL)-1beta, and activates the caspase-mediated pathways of alveolar epithelial apoptosis. The authors investigated whether gene transfer of the human antiapoptotic protein Bcl-2 by means of intratracheal adenoviral administration would preserve posttransplant lung function and reduce intragraft activated caspase activity and IL-1beta production in syngeneic rat donor lung grafts. METHODS: First, 1.0 x 10(9) plaque-forming units of AdvBcl-2 in phosphate-buffered saline (PBS), AdvNull empty vector in PBS, or PBS alone was administered intratracheally to ACI (RT1(a)) rats. Then, the left lungs were procured after 24 hr of in vivo incubation and orthotopically transplanted after 1 hr of cold ischemia into syngeneic recipients. After 2 hr of reperfusion, peak inspiratory pressures (PIP) and donor pulmonary vein PaO(2) was measured in all grafts; grafts were then excised and protein extracts were analyzed by enzyme-linked immunosorbent assay (ELISA) and activated caspase-3 and caspase-9 assays. RESULTS: Human Bcl-2 transgene overexpression in donor lung grafts was demonstrated by ELISA of tissue homogenates. Pretreatment of donor lungs with AdvBcl-2 resulted in reduced PIP and increased lung isograft pulmonary vein PaO(2) compared with AdvNull or PBS-alone treated controls. In addition, AdvBcl-2 pretreatment led to diminished cytochrome c release into cytosolic extracts and reduced intragraft IL-1beta production and inhibited intragraft caspase-3 and caspase-9 activity. CONCLUSIONS: Adenoviral overexpression of human Bcl-2 protein limits I/R injury in rat lung isografts. These data suggest that the use of Bcl-2 gene transfer to human lung donors may reduce the oxidative stress of pulmonary grafts after transplantation in clinical lung transplantation.