T-Cell Lymphoproliferative Disorders Following Allogeneic Bone Marrow Transplant: A Report of Two Cases and a Literature Review.

Post-transplantation lymphoproliferative disorders (PTLD) are a commonly occurring condition following solid organ transplantation (SOT) and, rarely, hematopoietic stem cell transplantation (HSCT). As the name suggests, a PTLD is a condition where there is a clonal proliferation of lymphoid cells that occurs as a complication after transplantation. Though the clonal origin cell is primarily associated with the B-cell lineage, there are existing cases in the literature describing PTLD from the T-cell lineage. Large granulocytic leukemia (LGL) is one rare T-cell lineage subtype that typically progresses with a passive clinical course and is discovered with leukocytosis and peripheral blood smears demonstrating large granules in lymphocytes. In this study, we describe two patients initially diagnosed with acute myeloid leukemia (AML) who were both found to have T-cell PTLD after undergoing allogeneic hematopoietic stem cell transplant. One was found with a clonal expansion of T-cells on flow cytometry and the other with LGL on peripheral blood and flow cytometry. This discovery was made at 16 and 20 months after their transplant respectively. Distinguishing factors for these two patients are demonstrated by the derivation of lymphoproliferative disorder from graft vs. host disease (GVHD) or viral etiology, which is significant as both of which have been shown to be associated with PTLD. Epstein-Barr virus (EBV) and cytomegalovirus (CMV) positivity have been shown to be associated with PTLD, and both our patients were EBV-negative but had harbored prior CMV infections. Additionally, they had a benign course with no development of cytopenias or symptoms since the time of diagnosis. These two cases add to the growing literature that is working to better characterize the rare development of LGL and, in general, T-cell PTLD following allogeneic bone marrow transplantation.

Report of Cholangiocarcinoma With Transheterozygous BRCA1 and BRCA2 Co-mutation.

Cholangiocarcinoma is an aggressive malignancy involving the epithelial cells of the intrahepatic, perihilar, or extrahepatic biliary tree. It is a disease that is often diagnosed late in its course and progresses quickly. Identifying genomic mutations may provide an important utility in predicting disease course and individualizing therapy for these patients. Mutations in BRCA1 or BCRCA2 genes have been increasingly documented in hepatobiliary malignancies, but they remain a relatively uncommon occurrence. Co-mutations in both BRCA1 and BRCA2 genes are even rarer, with no previously documented reports to our knowledge of BRCA co-positivity in a patient with a hepatobiliary malignancy. We present a case of a patient with cholangiocarcinoma found to have mutations in both BRCA1 and BRCA2 genes.

Group Video Feedback is an Effective and Efficient Tool for Enhancing Skills of Surgical Interns.

BACKGROUND: Our group has shown that personalized video feedback (PVF) is better than a task demonstration video at increasing wound closure skills among incoming surgical interns. However, offering PVF can be time-consuming. We sought to compare the educational effects and time required for group video feedback (GVF) and PVF. METHODS: We have mailed our matched incoming "surgical" interns a "welcome package" in mid-March for the past 3 y. The package includes similar resources each year. Incoming interns were asked to video record themselves performing six tasks three separate times between April 1 and June 15. After each submission in 2016 and 2017, incoming interns received 2 min of personalized feedback on their three separate wound closure videos (PVF). In 2018, incoming interns received 5 min of group-based feedback three separate times covering all six tasks (GVF). We compared performance (July Surgical Olympics) of these six skills against the interns from the previous 2 y who received PVF on only one skill (suturing). RESULTS: Twenty-three incoming interns received the pre-residency package and participated in the 2018 Surgical Olympics. This 2018 GVF class had a higher overall mean score for six stations (31.5 [standard deviation = ±7.7]) than the 2016 and 2017 PVF classes (25.6 [standard deviation = ±8]; P < 0.0001). Knot tying ability and suturing skill were similar between the classes. The GVF group performed better on the remaining four skills . The total time of surgical staff and educators spent per class in 2018 (GVF class) was 30 min and includes six tasks compared with 276 min of effort in each of the 2016 and 2017 classes (PVF included one task). CONCLUSIONS: GVF and PVF as a component of preemptive training had the same effect on improving suturing skills among the interns. GVF required less educator editing and voice over time. GVF is effective and efficient in enhancing incoming interns' performance in multiple skills.

A simulation-based selection process for trying to identify medical students who will become outstanding general surgery residents.

BACKGROUND: Selecting the right applicants for general surgery training is critical and difficult. We refined our selection process by using a pre-interview preparation package and simulation-based assessments. METHODS: Sixty applicants invited for categorical general-surgery residency interview were mailed an educational package which included a link to instructional videos, surgical instruments and low-cost models for suturing, open knot tying, and adrenal anatomy knowledge. During the interview day, applicants participated in a 48-min simulation-based assessment consisting of same tasks included in the package. Performance scores were used to assist in ranking applicants. The matched 2018class was compared to our previous intern classes on several objective assessments (Surgical-Olympics and ABSITE score). RESULTS: Students scored >50tile moved high in our final rank-list. The 2018 class scored significantly higher in 10 of 15 Surgical-Olympic stations compared to our 2015-17class with no significant difference on ABSITE score. CONCLUSIONS: By mailing out a pre-interview welcome package and adding a simulation based assessment to our General Surgery categorical interview process, we believe early objective data suggests we positively influenced our 2018 NRMP match.

Can the Perceived Difficulty of a Task Enhance Trainee Performance?

BACKGROUND: Human understanding of how to efficiently train learners in procedural skills is imperfect. The concept of self-efficacy - confidence in one's ability to successfully complete a task - may be useful to learners. Theories of motivation and instructional design suggest there are specific targets for improving learner success. We aimed to study the effects of induced conceptions of ability on motor learning using both undergraduate and medical students. METHODS: Forty undergraduate and medical students underwent a 15-minute training session teaching the basics of colonoscopy on a low-cost, moderate fidelity colonoscopy simulation model. Students were then tasked to intubate the cecum of a similarly constructed colonoscopy model with a real colonoscope. Before each task, participants were given a note which either read "90% of your peers completed the task in less than 5 minutes" (positive [+] comparison group) or "10% of your peers completed the task in less than 5 minutes" (negative [-] comparison group). Immediately after receiving the note, participants were then asked to complete a self-efficacy questionnaire, ranking their confidence on a scale from 0 to 10 for successfully completing the task. A NASA TLX was collected to understand the students' mental effort with the task. Participants then underwent stratified randomization into 2 crossover groups (G1 = + note, then - note; G2 = - note, then + note) and again performed the colonoscopy task. Following the session completion, all students had received both notes and crossed over to complete both tasks. Time spent on both tasks and task completion (reaching the cecum) was the measured outcomes. RESULTS: Self-efficacy (confidence) levels were significantly higher in the positive note condition for both comparison groups in (p < 0.05). However, task completion rates were higher in the negative note group in Task 1 (p < 0.05) and the same in Task 2 (p = 0.6). Time spent by participants in each task was longer in the negative note groups in both tasks (p = 0.06 in Task 1; p = 0.07 in Task 2). No difference was found between both groups in the mental effort after each task (Table 1). CONCLUSIONS: This prospective, cross-over study suggests that performance expectancies can be influenced by preinduced conceptions. Performance was enhanced in Task 1 when participants were given a relatively "low success rate prediction." This may be due to an enhanced focus that led to increased performance-while participants who were given the prediction of a "higher success rate" were more confident but performed less well. The crossover groups for Task 2 performed in a similar manner despite different confidence levels. This study supports the idea that self-efficacy expectations are relevant for trainee education and performance.

Surgical interns in 2018: Objective assessment suggests they are better but still lack critical knowledge and skill.

BACKGROUND: The transition from fourth-year medical student to surgical intern is difficult. A lack of repetitions, experience, and knowledge is problematic. We report our experience using simulation-based technical and nontechnical skills to assess the competency of surgical interns in July and January of their intern year. DESIGN: As part of a larger assessment effort, our general surgery interns (2010-2016) have been tested on performing an emergent cricothyrotomy, interpreting 2 arterial blood gases, and reading 3 chest x-rays in fewer than 7 minutes. We retrospectively analyzed general surgery interns' performance on these 3 tests (total score = 20). RESULTS: A total of 210 interns completed both July and January (identical) assessments. Overall mean scores improved from July (12.62 ± 3.44) to January (16.5 ± 2.46; P < .05). During the study period general surgery interns' mean baseline scores improved in both July (P < .05) and in January (P < .05). Although most individual general surgery interns did improve their total scores (92% improved, 3% same, 5% worse) between July and January (P < .05), in January 40% could not perform an emergent cricothyrotomy swiftly, and 6% missed a tension pneumothorax on chest x-ray. CONCLUSION: Our data suggest that surgical interns start residency training with low levels of skill and comprehension with emergent cricothyrotomy, arterial blood gas, and chest x-ray. They improve with 6 months of clinical and simulation training. Encouragingly, overall scores for both July and January assessments have improved during the study period. Given that some interns still struggle in January to perform these three tasks, we believe that 2018 interns are better, but still potentially lack critical knowledge and skill.

Low-cost materials yield high resolution assessment of anatomic knowledge in surgical residents.

INTRODUCTION: Knowledge of anatomy is essential for surgeons. We sought to determine whether it is possible to effectively assess and differentiate the anatomic knowledge of general surgery residents, using pieces of fabric and yarn. METHODS: Postgraduate years 2, 3, and 4 general surgery residents were assessed during a simulation-based assessment known as the Surgical X-Games. Residents were allowed 3 minutes to assemble the anatomic structures of the right upper quadrant region and 2 minutes to create the right lower quadrant of the abdomen, using colored felt and yarn. One point (each) was given for naming and placing the structures in the correct position. A checklist was used to assess trainees with a maximum combined score of 150 points. RESULTS: A total of 34 residents (postgraduate year 2 = 16, postgraduate year 3 = 8, postgraduate year 4 = 10) participated in the 2017 fall Surgical X-Games and 31 residents (postgraduate year 2 = 13, postgraduate year 3 = 9, postgraduate year 4 = 9) participated in the spring Surgical X-Games. Total scores increased respective to the level of clinical training in both the fall Surgical X-Games (postgraduate year 2 = 77, postgraduate year 3 = 84, postgraduate year 4 = 93, P = .04) and the spring Surgical X-Games (postgraduate year 2 = 94, postgraduate year 3 = 101, postgraduate year 4 = 109). We observed significant improvement in the right upper quadrant, right lower quadrant, and total scores from the fall to the spring postgraduate year (P < .001). CONCLUSION: Surgical residents showed an increase in mean anatomical scores from postgraduate years 2 to postgraduate years 3 to postgraduate years 4, using low-fidelity models. This inexpensive, 5-minute test based on a simple checklist may offer surgical educators insight in to residents' anatomic knowledge and potential readiness for clinical rotations.

Outcomes of laparoscopic and open CAPD catheter placement: A single-center experience.

BACKGROUND: Continuous Ambulatory Peritoneal Dialysis (CAPD) catheter placement is typically a straightforward surgical procedure performed on chronically ill patients with end-stage renal disease (ESRD). Post-operative outcomes and reoperative rates vary greatly in the medical literature. We report our experience using both minimally invasive and open techniques in placing CAPD catheters and offer our surgical outcomes. METHODS: This study is an IRB-approved, retrospective review (2005-2018) of all patients undergoing CAPD catheter placement at Mayo Clinic-Rochester. Analysis focused on specific patient outcomes, including early (< 30 days) versus late (≥ 30 days) complication and reoperation rates. RESULTS: A total of 173 patients with ESRD (mean ASA score = 3.1) underwent laparoscopic (n = 22) and open (n = 151) CAPD catheter placement (mean follow-up = 309 days; range: 1-3497 days). The total index operation complication rate was 41%. The total index reoperation rate was 37% and was similar in open and laparoscopic approaches. CAPD catheters malfunctioned in 19 patients (11% of total) and each underwent reoperation. CAPD catheter infections occurred in 30 patients (17% of total), and 24 required reoperation; 6 patients were treated successfully with antibiotics. CAPD catheter migrations occurred in 21 patients (12% of total) and all underwent reoperation. CONCLUSION: Although CAPD catheter placements in patients with ESRD are technically easy to accomplish, the long term outcomes suggest as many as one in three patients will struggle with catheter function or infection. This study has led to changes in our technical CAPD catheter placement procedures, as well as the post-operative patient care algorithm.

The FES Test: Are We Ready?

PURPOSE: The FES hands-on skills test is administered using a $100,000 computer-based simulator. Few of our trainees have practiced on this device. Our aim was to evaluate our GS residents' baseline endoscopic skills and eventually develop a simulation-based endoscopy curriculum and clarify performance-based assessment criteria. METHODS: General surgery residents' colonoscopy skills were assessed using a computer-based endoscopy simulator (CBES) during their biannual simulation-based OSCE-type assessments. Trainees were asked to reach the ileum in <5 minutes with minimal patient pain and complications. Module 1 (easy) was assigned to PGY 1-4 residents and module 5 (hard) to both PGY 4s and 5s. The colonoscope insertion length, % time with no pain, % time in "red out", and complications were recorded. Performance grading criteria were driven by literature review and expert opinion. Residents were assessed in the fall 2017; they were then given scoring criteria, a step-by-step instruction manual, and a voluntary hands-on session with the CBES. Residents repeated the same assessment in the spring 2018. RESULTS: 30 PGY-1s, 12 PGY-2s, 8 PGY-3s, 9 PGY-4s and 7 PGY-5s GS residents participated in the fall colonoscopy assessment. In module 1, 66% of PGY-4s, 50% of PGY-3s, 8% of PGY-2s and 0% of the PGY-1s intubated the ileum (p<0.05). In module 5, 30% of PGY 5 and 22% of PGY 4 residents completed the task (p<0.05). 15 PGY-1s, 5 PGY-2s, 1 PGY-3, 2 PGY-4s, and 1 PGY-5 participated in the voluntary hands-on session. All residents completing the fall assessment undertook the same task in the spring. In module 1, 89% of PGY-4s, 100% of the PGY-3s, 75% of PGY-2s and 70% of the PGY-1s completed the task. In module 5, 30% of PGY 5 and 34 % of PGY 4 residents completed the task. Residents who participated in the voluntary hands-on session (n= 24, 96% task completion) outperformed residents (n= 42, 64% task completion) that did not participate (p<0.05). CONCLUSIONS: Most of our GS residents could not initially intubate the ileum using the CBES. Prior experience with the CBES was the only factor strongly correlated with successful task completion. A voluntary hands-on teaching session allowed 96% of participating trainees to subsequently achieve CBES task completion. Developing a formal simulation-based curriculum suggests we can better prepare surgical trainees for the FES exam.