General Surgery Resident Participation in a Mandatory Wellness Program: Six Years Later.

INTRODUCTION: Following the approval of a resident-created physician wellness program in 2016, an initial survey demonstrated majority support for the implementation of a mandatory curriculum. The purpose of this study is to survey surgical residents about the wellness curriculum six years after implementation and re-evaluate preference for mandatory participation. METHODS: In 2016, the CORE7 Wellness Program didactic sessions were integrated into the general surgery resident education curriculum. A comparison between 2016 and 2022 resident survey results was done to examine overall approval and resident experience. RESULTS: A total of 25 general surgery residents responded to the 2022 survey which equaled to a response rate of 67.5% compared to a response rate of 87.1% in 2016. Similar to the results in 2016, there was unanimous support (100%, n = 25) in favor of the ongoing development of a general surgery wellness program. The majority of residents (88% versus 85.2% in 2016) preferred quarterly "wellness half-days" remain a mandatory component of the program. In 2016, most of the residents (50%) stated that the reason for mandatory preference for wellness half-days was ease of explanation to faculty. In 2022, the reason changed to a combination of reasons with most residents (59%) selecting ease of explanation to attendings, feeling too guilty otherwise to leave the shift, and forcing the resident to think about self-care. Complaints about taking a wellness half-day from other team members increased from 29% in 2016 to 48% in 2022. CONCLUSIONS: Six years after implementation, there is unanimous support for the mandatory components of a general surgery residency wellness curriculum. Increased perceived complaints from faculty and staff about resident wellness present an opportunity for improvement.

Incidental Intraoperatively Detected Choledocholithiasis: A General Surgeon's Approach to Management.

Background Up to 15% of patients with cholelithiasis have choledocholithiasis, with almost 10% not detected pre-operatively. Our study aims to quantify the prevalence of incidental choledocholithiasis during routine intra-operative cholangiogram (IOC), identify the best management pathway, and identify reliable pre-operative factors to predict choledocholithiasis. Methods We conducted a single-centre, retrospective cohort study at St John of God Midland Hospital in Western Australia, Perth, on 880 consecutive patients who underwent cholecystectomies performed by 15 surgeons between January 2, 2020, and December 30, 2021.  Results The overall choledocholithiasis rates were 10.6% (93), with 4.0% (35) diagnosed pre-operatively and 6.6% (58) diagnosed during IOC. In all, 50% of incidental choledocholithiasis during IOC were managed with hyoscine butylbromide, with a 55.2% success rate; 22.4% of patients received octreotide, with a 61.5% success rate; and 8.6% of patients underwent trans-cystic bile duct exploration (TCBE) and 8.6% underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP), both with 100% success rates. Choledocholithiasis most commonly presents with gallstone pancreatitis, with a median aspartate aminotransferase (AST) level 7.2 times and alanine transaminase (ALT) level 7.8 times higher than those of patients without choledocholithiasis. Magnetic resonance cholangiopancreatography (MRCP) was the most sensitive in identifying choledocholithiasis with a 66.7% pickup rate. The median common bile duct (CBD) diameter on ultrasound was 8 mm, computerised tomography scans were 11 mm, and MRCP was 9 mm. Conclusion One in 10 cholecystectomies will be complicated with choledocholithiasis, and over half will be incidentally diagnosed during routine IOC. We propose IOC in all cases and hyoscine butylbromide, octreotide, and saline flushes as first-line treatment; if unsuccessful, TCBE is performed. Gallstone pancreatitis, markedly elevated AST/ALT, and imaging showing CBD ≥8 mm may serve as early predictors of choledocholithiasis.

Valproic acid as a radio-sensitizer in glioma: A systematic review and meta-analysis.

Background: Histone deacetylase inhibitors (HDACi) including valproic acid (VPA) have the potential to improve radiotherapy (RT) efficacy and reduce treatment adverse events (AE) via epigenetic modification and radio-sensitization of neoplastic cells. This systematic review and meta-analysis aimed to assess the efficacy and AE associated with HDACi used as radio-sensitizers in adult solid organ malignancy patients. Methods: A systematic review utilized electronic searches of MEDLINE(Ovid), Embase(Ovid), The Cochrane Library, and the International Clinical Trials Registry Platform to identify studies examining the efficacy and AEs associated with HDACi treatment in solid organ malignancy patients undergoing RT. Meta-analysis was performed with overall survival (OS) reported as hazard ratios (HR) as the primary outcome measure. OS reported as median survival difference, and AEs were secondary outcome measures. Results: Ten studies reporting on the efficacy and/or AEs of HDACi in RT-treated solid organ malignancy patients met inclusion criteria. All included studies focused on HDACi valproic acid (VPA) in high-grade glioma patients, of which 9 studies (n = 6138) evaluated OS and 5 studies (n = 1055) examined AEs. The addition of VPA to RT treatment protocols resulted in improved OS (HR = 0.80, 95% CI 0.67-0.96). No studies focusing on non-glioma solid organ malignancy patients, or non-VPA HDACi met the inclusion criteria for this review. Conclusions: This review suggests that glioma patients undergoing RT may experience prolonged survival due to HDACi VPA administration. Further randomized controlled trials are required to validate these findings. Additionally, more research into the use of HDACi radio-adjuvant treatment in non-glioma solid organ malignancies is warranted.

Pharmacist-Initiated De-Prescribing Efforts Reduce Inappropriate Continuation of Acid-Suppression Therapy Initiated in the ICU.

OBJECTIVES: Stress ulcer prophylaxis initiated for intensive care unit (ICU)-specific indications is often continued upon transfer or discharge despite lack of indication. This quality improvement initiative aimed to achieve a 25% reduction from baseline in ICU-initiated acid suppression therapy prescriptions by May 2021. METHODS: This initiative was conducted in adult ICU patients at Boston Medical Center from July 2020 through May 2021. A multidisciplinary approach to de-prescribing was utilized, including the implementation of formalized stress ulcer prophylaxis criteria and an electronic handoff tool used to identify patients appropriate for assessment of acid suppression therapy continuation post-ICU stay. The primary outcome measure was the number of discharge prescriptions for ICU-initiated acid suppression therapy. Secondary endpoints included incidence of de-prescribing workflow failures, percentage of acid suppression therapy discharge prescriptions with inappropriate indications, and incidence of stress ulcer-related gastrointestinal bleeding. RESULTS: A 55% decrease in ICU-initiated acid suppression therapy discharge prescriptions occurred after implementing the multidisciplinary workflow. The decrease was sustained for 28 weeks through the completion of the study. CONCLUSIONS: Implementation of a pharmacist-initiated electronic handoff tool along with provider education and creation of formalized stress ulcer prophylaxis criteria may reduce the number of ICU-initiated acid suppression therapy prescriptions inadvertently or inappropriately continued at discharge.

Histone deacetylase inhibitor use as a radiosensitizer in solid organ malignancies: a systematic review protocol.

OBJECTIVE: The objective of this review is to evaluate the efficacy and adverse effects of histone deacetylase inhibitors (HDACi) in combination with radiotherapy for the treatment of solid organ malignancies. INTRODUCTION: Histone deacetylase inhibitors are a diverse class of drugs that have shown promise as novel anti-cancer therapeutics via epigenetic modification and radiosensitization of neoplastic cells. The aim of HDACi in combination with radiotherapy is to reduce radiation dosage requirements, improve radiotherapy efficacy, and reduce treatment side effects. INCLUSION CRITERIA: This review will consider studies utilizing HDACi in conjunction with radiotherapy in adult patients with solid organ malignancy. Sources to be included in this review include experimental and quasi-experimental study designs, analytical studies, and descriptive observational studies. METHODS: A systematic review of effectiveness will be conducted in accordance with JBI methodology. A detailed search will be conducted via MEDLINE (Ovid), Embase (Ovid), and Scopus. A search of the Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform, and ClinicalTrials.gov will also be performed for relevant trials. Inclusion and exclusion criteria will be utilized to select studies, and papers selected for retrieval will be assessed for methodological validity using the JBI critical appraisal instruments. Evidence will be extracted from eligible studies and summarized using quantitative methods, where possible, including meta-analysis and assessment of heterogeneity. Where statistical pooling is not possible, the findings will be presented in diagrammatic or tabular form accompanied by a narrative summary. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021293005.

Assessment of a vessel and tissue-sealing device for ovariectomy in chickens to evaluate the potential application of the procedure to other avian species.

OBJECTIVE: To assess the feasibility of a novel technique involving a vessel and tissue-sealing device (VTSD) for ovariectomy in chickens to evaluate the potential application of the procedure to other avian species. ANIMALS: 20 domestic laying hens (Gallus domesticus), of which 10 were immature (< 4 months old) and 10 were adults (> 18 months old). PROCEDURES: Ovariectomy was performed with a VTSD through a left lateral celiotomy. Birds were allowed to recover for 14 days after the procedure and then were euthanized for necropsy. A board-certified veterinary pathologist performed complete necropsies, with particular attention to identifying any remaining ovarian tissue. RESULTS: All birds survived the procedure. For the mature and juvenile birds, the mean ± SD durations of anesthesia (interval from intubation to extubation) were 67.2 ± 7.6 minutes and 50.5 ± 5.1 minutes, respectively, and mean durations of surgery were 45.3 ± 8.5 minutes and 31.6 ± 5.1 minutes, respectively. Three birds had severe hemorrhage during ovariectomy. At necropsy, ovarian tissue was present grossly in 2 mature birds and histologically in 6 additional birds (2 mature and 4 juvenile birds), indicating incomplete excision in 8 (40%) birds. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that the evaluated VTSD can be used to successfully perform ovariectomies in both juvenile and mature chickens, although the procedure was associated with major hemorrhage and incomplete excision of ovarian tissue in some cases. Use of this VTSD for ovariectomy in birds of other species, particularly birds with reproductive tract disease, should be investigated.

Poetry for Veterans: Using Poetry to Help Care for Patients in Palliative Care-A Case Series.

Background: Although there is growing evidence that close reading of literature and reflective writing can improve providers' appreciation of the patient experience, foster physician development, and combat burnout, there has been less work on the experience of reading literature with patients, and even less literature about its effect on those facing serious or life-threatening illness. In addition, longer form reading may be unsuitable for some patient populations, given high burden of fatigue and possible contribution of delirium. Time pressure may also preclude discussion by a practitioner working in a busy clinical context. Hypothesis: We feel the condensed medium of poetry presents a natural opportunity to engage patients with the medical humanities, helping them to articulate difficult or joyful experiences, and/or serving as necessary diversion when facing serious illness. Project Description: Poetry for patients-a project developed through collaboration between Northwestern Memorial Hospital, The Jesse Brown VA, and the Poetry Foundation in Chicago, an independent literary organization committed to a vigorous presence for poetry in our culture-has developed three short collections of poems, and an accompanying discussion guides for use specifically with patients and families. Hereunder, we present three case examples of a short (10-30 minutes) reading session with patients demonstrating that it is feasible to incorporate reading poetry with patients facing serious illness. Potential therapeutic value includes helping patients to articulate pain and joy, giving patients a vehicle to recapture their creative voice, and altering the power dynamics inherit to the provider-patient relationship. We have also noted enhanced life review, often on themes otherwise difficult to access. In turn, these readings have deepened our ability to see out patients as creative, intellectual, and larger than their medical illness.

Management of Minor Traumatic Brain Injury in an ED Observation Unit.

INTRODUCTION: Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress. METHODS: This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention. RESULTS: There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 - 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 - 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention. CONCLUSION: Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Phosphoproteomic profiling of mouse primary HSPCs reveals new regulators of HSPC mobilization.

Protein phosphorylation is a central mechanism of signal transduction that both positively and negatively regulates protein function. Large-scale studies of the dynamic phosphorylation states of cell signaling systems have been applied extensively in cell lines and whole tissues to reveal critical regulatory networks, and candidate-based evaluations of phosphorylation in rare cell populations have also been informative. However, application of comprehensive profiling technologies to adult stem cell and progenitor populations has been challenging, due in large part to the scarcity of such cells in adult tissues. Here, we combine multicolor flow cytometry with highly efficient 3-dimensional high performance liquid chromatography/mass spectrometry to enable quantitative phosphoproteomic analysis from 200 000 highly purified primary mouse hematopoietic stem and progenitor cells (HSPCs). Using this platform, we identify ARHGAP25 as a novel regulator of HSPC mobilization and demonstrate that ARHGAP25 phosphorylation at serine 363 is an important modulator of its function. Our approach provides a robust platform for large-scale phosphoproteomic analyses performed with limited numbers of rare progenitor cells. Data from our study comprises a new resource for understanding the molecular signaling networks that underlie hematopoietic stem cell mobilization.

High-level Gpr56 expression is dispensable for the maintenance and function of hematopoietic stem and progenitor cells in mice.

Blood formation by hematopoietic stem cells (HSCs) is regulated by a still incompletely defined network of general and HSC-specific regulators. In this study, we analyzed the role of G-protein coupled receptor 56 (Gpr56) as a candidate HSC regulator based on its differential expression in quiescent relative to proliferating HSCs and its common targeting by core HSC regulators. Detailed expression analysis revealed that Gpr56 is abundantly expressed by HSPCs during definitive hematopoiesis in the embryo and in the adult bone marrow, but its levels are reduced substantially as HSPCs differentiate. However, despite enriched expression in HSPCs, Gpr56-deficiency did not impair HSPC maintenance or function during steady-state or myeloablative stress-induced hematopoiesis. Gpr56-deficient HSCs also responded normally to physiological and pharmacological mobilization signals, despite the reported role of this GPCR as a regulator of cell adhesion and migration in neuronal cells. Moreover, Gpr56-deficient bone marrow engrafted with equivalent efficiency as wild-type HSCs in primary recipients; however, their reconstituting ability was reduced when subjected to serial transplantation. These data indicate that although GPR56 is abundantly and selectively expressed by primitive HSPCs, its high level expression is largely dispensable for steady-state and regenerative hematopoiesis.

Cdx2 ectopic expression induces gastric intestinal metaplasia in transgenic mice.

BACKGROUND & AIMS: Intestinal-type gastric cancer is often preceded by intestinal metaplasia in humans. The genetic events responsible for the transdifferentiation that occurs in intestinal metaplasia are not well understood. Cdx2, a transcription factor whose expression is normally limited to the intestine, has been detected in gastric intestinal metaplasia. Cdx2 induces differentiation of intestinal epithelial cells in vitro; therefore, we sought to establish whether a causal relationship exists between Cdx2 activation and intestinal metaplasia. METHODS: Cdx2 expression was directed to the gastric mucosa in transgenic mice using cis-regulatory elements of Foxa3 (Hnf3gamma). Transgenic mice were analyzed for histologic and gene expression changes. RESULTS: Histologic examination of the gastric mucosa of the Foxa3/Cdx2 mice revealed the presence of alcian blue-positive intestinal-type goblet cells, a hallmark of intestinal metaplasia. In addition, Cdx2 induced the expression of intestine-specific genes. CONCLUSIONS: Gastric expression of Cdx2 alone was sufficient to induce intestinal metaplasia in mice. These mice represent a powerful tool to investigate the molecular mechanisms that promote intestinal metaplasia. Moreover, as gastric cancer in humans is often preceded by intestinal metaplasia, the phenotype described here strongly suggests involvement of Cdx2 in the initiation of the process leading to intestinal neoplasia of the gastric mucosa.