Deficiency of leukocyte-specific protein 1 (LSP1) alleviates asthmatic inflammation in a mouse model.

BACKGROUND: Asthma is a major cause of morbidity and mortality in humans. The mechanisms of asthma are still not fully understood. Leukocyte-specific protein-1 (LSP-1) regulates neutrophil migration during acute lung inflammation. However, its role in asthma remains unknown. METHODS: An OVA-induced mouse asthma model in LSP1-deficient (Lsp1-/-) and wild-type (WT) 129/SvJ mice were used to test the hypothesis that the absence of LSP1 would inhibit airway hyperresponsiveness and lung inflammation. RESULTS: Light and electron microscopic immunocytochemistry and Western blotting showed that, compared with normal healthy lungs, the levels of LSP1 were increased in lungs of OVA-asthmatic mice. Compared to Lsp1-/- OVA mice, WT OVA mice had higher levels of leukocytes in broncho-alveolar lavage fluid and in the lung tissues (P < 0.05). The levels of OVA-specific IgE but not IgA and IgG1 in the serum of WT OVA mice was higher than that of Lsp1-/- OVA mice (P < 0.05). Deficiency of LSP1 significantly reduced the levels of IL-4, IL-5, IL-6, IL-13, and CXCL1 (P < 0.05) but not total proteins in broncho-alveolar lavage fluid in asthmatic mice. The airway hyper-responsiveness to methacholine in Lsp1-/- OVA mice was improved compared to WT OVA mice (P < 0.05). Histology revealed more inflammation (inflammatory cells, and airway and blood vessel wall thickening) in the lungs of WT OVA mice than in those of Lsp1-/- OVA mice. Finally, immunohistology showed localization of LSP1 protein in normal and asthmatic human lungs especially associated with the vascular endothelium and neutrophils. CONCLUSION: These data show that LSP1 deficiency reduces airway hyper-responsiveness and lung inflammation, including leukocyte recruitment and cytokine expression, in a mouse model of asthma.

Major Histocompatibility Complex-B haplotype and ovarian graft response.

Gonadal tissue transfer is considered one of the best methods to preserve genetic variability. Poultry hosts can receive a gonad from a donor of a different genetic background, sustain the growth of this graft, and produce gametes from it. Unfortunately, the host's strong immune response may significantly reduce the gonadal graft's ability to reach maturity. Our study aimed to evaluate the influence of MHC-B alleles in rejecting a gonadal graft of similar or different genetic backgrounds. In the first experiment, ovarian tissue was transplanted to chicks of similar genetic backgrounds, either Lohmann White (LW) with variable MHC-B or Barred Rock (BR) with fixed MHC-B. The sustained growth of donor ovarian tissues occurred in (4/7 hosts) BR (MHC-B matched) hosts only-one of these graft-positive-BR hens produced eggs derived from the donor ovary. No grafts were recovered when the host and the donor had an LW background (0/9; MHC-B mismatched). In the second experiment, ovarian transplantation was done between chicks of either similar or different genetic backgrounds (Brown Leghorn [BL], BR, and BL/BR F1). The 2 pure lines contained only one MHC-B allele, whereas the F1 heterozygotes had both. All host birds were given a daily dose of an immunosuppressant (mycophenolate mofetil) until maturity. The success rate was assessed by microsatellite genotype confirmation of donor-derived ovaries plus physiological and histological analyses of ovarian grafts. In this second experiment, 11 out of 43 ovarian hosts laid eggs. However, all fertilized eggs from these hens were derived from the remnant host ovarian tissue, not from the donor ovaries. A necropsy assessment was done on all 43 host birds. Ten donor grafts were recovered from hosts having matched (6 hosts) and mismatched (4 hosts) MHC-B, and none were functional. Interestingly, 6 of them were enclosed by a serous membrane capsule filled with fluid and had various tissue growth. In addition, clusters of immune cells were observed in all recovered donor grafts. Our results demonstrated that genetic background could greatly influence the success of gonadal transfer in chickens.

Association of research timing with surgery resident perceptions of operative autonomy and satisfaction: A multi-institutional study.

BACKGROUND: General surgery residents commonly engage in research years after the second (Post-postgraduate year 2 [PostPGY2]) or third (PostPGY3) clinical training year. The impact of dedicated research training timing on training experience is unknown. Our aim was to examine the progression of residents' perceived meaningful operative autonomy and evaluate career satisfaction, in relation to research timing. METHODS: Categorical surgery residents with 2-year research requirements were surveyed regarding perceived autonomy for laparoscopic appendectomy, laparoscopic cholecystectomy, and right hemicolectomy and satisfaction with the impact of dedicated research training on professional development. Meaningful operative autonomy was defined as Zwisch scores ≥3 (passive help or supervision only). RESULTS: Residents from 17 programs participated (n = 233, 30.6%); 48% were PostPGY2. PostPGY3 residents were more likely to perceive meaningful operative autonomy when starting dedicated research training (laparoscopic appendectomy: 98% vs 74%, P < .001; laparoscopic cholecystectomy: 87% vs 48%, P < .001; right hemicolectomy: 27% vs 3%, P < .001). Meaningful operative autonomy declined during dedicated research training but was still higher for PostPGY3 residents for laparoscopic appendectomy (84% vs 42%, P < .001) and laparoscopic cholecystectomy (68% vs 30%, P < .001). By PGY4, PostPGY2 residents reported rates of meaningful operative autonomy comparable to PostPGY3 through training completion. A higher proportion of PostPGY3 residents reported dedicated research training satisfaction (90% vs 78%, P = .01). Training at PostPGY3 programs (odds ratio, 3.06, 95% confidence interval, 1.38-6.80) and postresearch training stage (compared with preresearch residents, odds ratio, 3.25, 95% confidence interval, 1.06-10.0) were independently associated with satisfaction. CONCLUSION: Significant differences existed in the progression of perceived operative autonomy and dedicated research training satisfaction between PostPGY2 and PostPGY3 residents. These results could help surgical educators make individualized decisions regarding research timing to promote surgical skill acquisition and resident well-being.

Persistence of Gender Bias Over Four Decades of Surgical Training.

OBJECTIVE: Female surgeons face gender-specific obstacles during residency training, yet longitudinal data on gender bias experienced by female surgery residents are lacking. We aimed to investigate the evolution of gender bias, identify obstacles experienced by female general surgery residents, and discuss approaches to supporting female surgeons during residency training. METHODS: Between August 2019 and January 2021, we conducted a retrospective cohort study using structured telephone interviews of female graduates of the UCLA General Surgery Residency training program. Responses of early graduates (1981-2009) were compared with those of recent graduates (2010-2020). Quantitative data were compared with Fisher's exact tests and Chi-squared tests. Interview responses were reviewed to catalog gender bias, obstacles experienced by female surgeons, and advice offered to training programs to address women's concerns. RESULTS: Of 61 female surgery residency graduates, 37 (61%) participated. Compared to early graduates (N = 20), recent graduates (N = 17) were significantly more likely to pursue fellowship training (100% vs. 65%, p < 0.01) and have children before or during residency (65% vs. 25%, p = 0.02). A substantial proportion in each cohort experienced some form of gender bias (71% vs. 85%, p = 0.43). Compared to early graduates, recent graduates were significantly less likely to report experiencing explicit gender bias (12% vs. 50%, p = 0.02) but equally likely to report implicit gender bias (71% vs. 55%, p = 0.50). Female graduates across the decades advocated for specific measures to champion work-life balance in residency (51%), strengthen female mentorship (49%), increase childcare support (41%), and promote women into leadership positions (32%). CONCLUSIONS: While having children during residency has become more common and accepted over the decades, female surgery residents continue to experience implicit gender bias in the workplace. Female surgeons advocate for targeted interventions to establish systems for parental leave, address gender bias, and strengthen female mentorship.

Web-based portfolios: a valuable tool for surgical education.

BACKGROUND: Our residency program developed and implemented an online portfolio system. In the present communication, we describe this system and provide an early analysis of its effect on competency-based performance and acceptance of the system by the residents. MATERIALS AND METHODS: To measure competency-based performance, end-of-rotation global evaluations of residents by faculty completed before (n = 1488) and after (n = 697) implementation of the portfolio were compared. To assess acceptance, residents completed a 20-question survey. RESULTS: Practice-based learning and improvement improved following implementation of the portfolio system (P = 0.002). There was also a trend toward improvement in the remaining competencies. In the survey tool (response rate 69%), 95% of the residents agreed that the purpose and functions of the system had been explained to them, and 82% affirmed understanding of ways in which the system could help them, although fewer than half reported that their portfolio had aided in their development of the competencies. All residents appreciated the system's organizational capabilities, and 87% agreed that the portfolio was a useful educational tool. CONCLUSIONS: This web portfolio program is a valuable new instrument for both residents and administrators. Early analysis of its impact demonstrates a positive effect across all competencies, and survey analysis revealed that residents have a positive view of this new system. As the portfolio is further incorporated into the educational program, we believe that our residents will discover new tools to craft a career of genuine self-directed learning.

Standardized Multi-Institutional Mock Oral Examination: A Feasible and Valuable Educational Experience for General Surgery Residents.

INTRODUCTION: Mock oral examinations (MOE) are used to prepare residents and assess their readiness for the American Board of Surgery Certifying Exam (ABSCE). Delivery of MOEs varies by institution and previous studies have demonstrated significant implementation barriers such as availability of faculty examiners and exam scenarios. OBJECTIVE: To assess the value and participant satisfaction of a standardized multi-institutional MOE for general surgery residents. PARTICIPANTS: Thirty-three general surgery residents and 37 faculty members from 3 institutions participated in a regional MOE. Residents were examined in three 20-minute sessions. Faculty examiners were given a wide selection of prescripted exam scenarios and instructed to use standardized grading rubrics during a brief orientation on the day of the exam. All participants were surveyed on their overall experience. RESULTS: Of 33 participating residents, 26 (79%) passed the MOE (92% of R5, 91% R4, and 50% of R3). Response rates were 91% for residents, and 57% for faculty members respectively. Most respondents were satisfied with the overall exam experience (88%), standardized question quality (86%) and question variety (82%). A total of 92% of respondents agreed that the time, effort, and cost of the MOE was justified by its educational value to residents. Higher medical knowledge ratings assigned by faculty examiners correlated with stronger trainee performance (ß = 0.48; 95% confidence interval [CI] 0.29-0.66), while patient care and interpersonal communication skill ratings were not associated with trainee performance. The standardized grading rubric achieved moderate inter-rater reliability among examiner pairs with 70.6% agreement (Kappa 0.47). CONCLUSIONS: General Surgery residents and faculty perceived the standardized multi-institutional MOE to be a highly satisfactory educational experience and valuable assessment tool. Developing a repertoire of scripted exam scenarios made it feasible to recruit sufficient faculty participants, and standardizing grading rubrics allowed for a consistent exam experience with moderate inter-rater reliability.

Use of Entrustable Professional Activities in the Assessment of Surgical Resident Competency.

Importance: Competency-based assessments of surgical resident performance require metrics of entrustable autonomy. Objectives: To designate entrustable professional activities (EPAs) in global performance and in specific operations, and to identify differences in perceived capability, autonomy, and expectations between surgical faculty and residents. Design, Setting, and Participants: This survey study was conducted from August 9, 2016, through August 24, 2016, in the Department of Surgery at the UCLA David Geffen School of Medicine. The survey instrument consisted of 5-point Likert scales for assessing perceptions of entrustability for 5 global and 5 operative EPAs. Faculty members were surveyed regarding resident capabilities and expected capabilities by postgraduate year. Residents were surveyed regarding their own capabilities, actual autonomy entrusted in the last EPA performed, and expected capabilities. Main Outcomes and Measures: Differences in mean ratings were assessed across 7 comparison domains. Results: Among 78 total faculty members, 31 (40%) participated in the survey. Among 49 residents, 39 (80%) participated in the survey. Residents generally rated their global EPA performance higher than the faculty did (mean, 3.7 vs 2.8; P < .01), but operative EPA performance ratings were equivalent (mean, 2.7 vs 2.4; P < .12). Faculty members perceived senior residents as underperforming expectations in operative EPAs. Most faculty members (80%) expected residents not to be independently capable of performing complex operations by graduation. Faculty members perceived residents in postgraduate years 4 and 5 to have greater operative capability than the level of autonomy entrusted to those residents (95% CI, 3.3-3.5 vs 1.9-2.2). Conclusions and Relevance: Global and operative EPAs are practical for developing competency-based curricula. Graduated autonomy should be granted to improve the operative experience for residents.

Comparative Analysis of Simulated versus Live Patient-Based FAST (Focused Assessment With Sonography for Trauma) Training.

OBJECTIVE: To investigate whether simulated patient (SP)-based training has comparable efficacy as live patient (LP)-based training in teaching Focused Abdominal Sonography for Trauma (FAST) knowledge and skill competencies to surgical residents. DESIGN: A randomized pretest/intervention/posttest controlled study design was employed to compare the participants' performance in written and practical examinations regarding FAST examination after SP-based versus LP-based training. SETTING: University-based general residency program at a single institution. PARTICIPANTS: A total of 29 general surgery residents of various training levels and sonographic experience were recruited by convenience sampling. RESULTS: There was no correlation between subjects' baseline training level or sonographic experience with either the posttest-pretest score difference or the percentage of subjects getting all 4 windows with adequate quality. There was no significant difference between the improvement in written posttest-pretest scores for SP and LP group, which were 33 ± 9.6 and 31 ± 6.8 (p = 0.40), respectively. With regard to performance-based learning efficacy, a statistically higher proportion of subjects were able to obtain all 4 windows with adequate quality among the LP than the SP group (6/8 vs 1/8, p = 0.01). CONCLUSION: SP- and LP-based FAST training for surgical residents were associated with similar knowledge-based competency acquisition, but residents receiving LP-based training were better at acquiring adequate FAST windows on live patients. Simulation training appeared to be a valid adjunct to LP practice but cannot replace LP training. Future investigations on how to improve simulation fidelity and its training efficacy for skill-based competencies are warranted.

The Perfect Storm Is on the Horizon!

PURPOSE: Provide analysis of data identifying the impending mass turnover of Directors and Coordinators of General Surgery residency programs and the potential effect on successful continuing accreditation including the ACGME Next Accreditation System (NAS) and associated self study. METHODS: The Association of Residency Coordinators in Surgery, Executive Committee (ARCS EC) anonymously surveyed 254 general surgery Program Coordinators in September/October 2016. This represents 60`% of all the members within the Association of Residency Coordinators in Surgery. Survey was accomplished using SurveyMonkey. Questions included demographics and experience of the Director and Coordinator, accreditation status, significant job stressors, and potential retirements or position changes planned or possible. RESULTS: 153 (60%) respondents completed the survey. Data from the survey indicates that 67% of Program Directors have been in their position less than six (6) years. 34% of Program Coordinators have been in their position less than five (5) years. 56% of coordinators have been on the job less than ten (10) years. Coordinators in 76% of programs reported significant levels of burnout. 59% have considered resigning from their position in the past year. Participants consistently reported increasing responsibilities and expectations combined with declining or inadequate levels of support as sources of job stress. Other contributors to Coordinator burnout were identified as related to the additional ACGME accreditation requirements and salaries not commensurate with workload. CONCLUSION: This survey represents a sentinel preliminary look at the possible impending manning crisis in general surgery residency program leadership. A Program Director is supported by a Program Coordinators who are burned out and considering a job change. The resultant potential turnover in personnel and loss of collective program knowledge may have devastating ramifications to program accreditation. Subsequent survey of the workforce will evaluate proposed solutions and interventions to prevent this outcome and secure the future success of general surgery programs.

Assessment of resident operative performance using a real-time mobile Web system: preparing for the milestone age.

OBJECTIVE: To satisfy trainees' operative competency requirements while improving feedback validity and timeliness using a mobile Web-based platform. DESIGN: The Southern Illinois University Operative Performance Rating Scale (OPRS) was embedded into a website formatted for mobile devices. From March 2013 to February 2014, faculty members were instructed to complete the OPRS form while providing verbal feedback to the operating resident at the conclusion of each procedure. Submitted data were compiled automatically within a secure Web-based spreadsheet. Conventional end-of-rotation performance (CERP) evaluations filed 2006 to 2013 and OPRS performance scores were compared by year of training using serial and independent-samples t tests. The mean CERP scores and OPRS overall resident operative performance scores were directly compared using a linear regression model. OPRS mobile site analytics were reviewed using a Web-based reporting program. SETTING: Large university-based general surgery residency program. PARTICIPANTS: General Surgery faculty used the mobile Web OPRS system to rate resident performance. Residents and the program director reviewed evaluations semiannually. RESULTS: Over the study period, 18 faculty members and 37 residents logged 176 operations using the mobile OPRS system. There were 334 total OPRS website visits. Median time to complete an evaluation was 45 minutes from the end of the operation, and faculty spent an average of 134 seconds on the site to enter 1 assessment. In the 38,506 CERP evaluations reviewed, mean performance scores showed a positive linear trend of 2% change per year of training (p = 0.001). OPRS overall resident operative performance scores showed a significant linear (p = 0.001), quadratic (p = 0.001), and cubic (p = 0.003) trend of change per year of clinical training, reflecting the resident operative experience in our training program. Differences between postgraduate year-1 and postgraduate year-5 overall performance scores were greater with the OPRS (mean = 0.96, CI: 0.55-1.38) than with CERP measures (mean = 0.37, CI: 0.34-0.41). Additionally, there were consistent increases in each of the OPRS subcategories. CONCLUSIONS: In contrast to CERPs, the OPRS fully satisfies the Accreditation Council for Graduate Medical Education and American Board of Surgery operative assessment requirements. The mobile Web platform provides a convenient interface, broad accessibility, automatic data compilation, and compatibility with common database and statistical software. Our mobile OPRS system encourages candid feedback dialog and generates a comprehensive review of individual and group-wide operative proficiency in real time.

The effect of a dedicated endocrine surgery program on general surgery training: a single institutional experience.

BACKGROUND: The endocrine surgery program was established at the University of California, Los Angeles, in 2006 to enhance the educational experience of surgical residents in this area. The impact of this program on subjective and objective measures of resident education was prospectively tracked. METHODS: Resident case logs, American Board of Surgery In-Training Examination scores, self-assessment surveys, and annual rotation evaluations from July 2005 to June 2009 were reviewed. RESULTS: The mean number of endocrine cases reported by graduates doubled during the study period (from 18 to 36, P < .001). Self-assessment scores increased for thyroid (from 4.53 to 5.76, P = .04) and parathyroid (from 4.46 to 5.90, P = .03) disorders. The mean rating for the endocrine rotation (from 3.23 to 3.95, P = .005) improved, with specific increases in the quantity (from 3.05 to 3.74, P = .02) and quality (from 3.25 to 3.95, P = .002) of operative experience. Since 2006, trainees have coauthored 17 peer-reviewed reports and 3 textbook chapters on endocrine topics. CONCLUSIONS: The establishment of a dedicated endocrine surgery program has a measurable impact on resident education within this core content area.

The electronic residency application service application can predict accreditation council for graduate medical education competency-based surgical resident performance.

OBJECTIVE: Program directors often struggle to determine which factors in the Electronic Residency Application Service (ERAS) application are important in the residency selection process. With the establishment of the Accreditation Council for Graduate Medical Education (ACGME) competencies, it would be important to know whether information available in the ERAS application can predict subsequent competency-based performance of general surgery residents. METHODS: This study is a retrospective correlation of data points found in the ERAS application with core competency-based clinical rotation evaluations. ACGME competency-based evaluations as well as technical skills assessment from all rotations during residency were collected. The overall competency score was defined as an average of all 6 competencies and technical skills. RESULTS: A total of77 residents from two (one university and one community based university-affiliate) general surgery residency programs were included in the analysis. Receiving honors for many of the third year clerkships and AOA membership were associated with a number of the individual competencies. USMLE scores were predictive only of Medical Knowledge (p = 0.004). Factors associated with higher overall competency were female gender (p = 0.02), AOA (p = 0.06), overall number of honors received (p = 0.04), and honors in Ob/Gyn (p = 0.03) and Pediatrics (p = 0.05). Multivariable analysis showed honors in Ob/Gyn, female gender, older age, and total number of honors to be predictive of a number of individual core competencies. USMLE scores were only predictive of Medical Knowledge. CONCLUSIONS: The ERAS application is useful for predicting subsequent competency based performance in surgical residents. Receiving honors in the surgery clerkship, which has traditionally carried weight when evaluating a potential surgery resident, may not be as strong a predictor of future success.

Protected educational rotations: a valuable paradigm shift in surgical internship.

OBJECTIVE: The first year of surgical training sometimes includes marginally educational or service-related tasks with limited direct interactions with faculty. We instituted a prototype rotation to address the changing needs and expectations of our intern class. This study was designed to evaluate the new rotation 17 months after it was implemented. DESIGN: Interns spend 4 weeks in our outpatient surgery center. Elements of the rotation include performance of operative cases and perioperative management of outpatients under direct faculty supervision, daily one-on-one structured teaching sessions with faculty, and call coverage twice monthly. At the conclusion of the rotation, interns make a presentation on a topic of their choosing to a teaching conference. Rotation evaluations and case and work-hour logs for the outpatient surgery rotation (OSR) were compared with those for the remaining intern rotations combined. A faculty survey of the OSR also was conducted. RESULTS: The OSR consistently received maximum overall ratings (4 of 4), significantly higher than the average overall score for the remaining rotations (3.17, p < 0.01). Similarly, teaching by faculty, time spent in the operating room, and quality of operating room time were rated significantly higher than for the other intern rotations (p