Before the scalpel: Exploring surgical residents' preoperative preparatory strategies.

OBJECTIVE: This study sought to increase understanding of preoperative preparatory strategies utilised by senior surgical residents and identify how social and material forces come together to shape practice. SUMMARY/BACKGROUND DATA: Preoperative preparation can play a powerful role in operative learning. Residents rarely receive guidance, feedback, or explicit expectations on how to prepare for the OR. Understanding current practice and how to support preoperative preparation represents an important gap in our efforts to improve surgical training. METHODS: Constructivist grounded theory with sensitizing concepts from sociomateriality guided data collection and analysis. Fifteen senior surgical residents from a range of surgical disciplines were purposefully sampled and participated in an in-depth individual interview. Two return-of-finding focus groups followed with seven residents. Rigor was enhanced through constant comparison, theoretical sampling, pursuit of discrepant data, and investigator triangulation. RESULTS: Residents utilised a range of strategies addressing four areas of focus: develop technical skills, improve procedural knowledge, enhance patient-specificity, and know surgical preferences. However, residents also described receiving limited guidance on what it means to 'be prepared' and experience significant challenges in achieving preparedness. A mix of social and material things that enabled or constrained preparatory efforts influenced individual strategies. These included rotation structure, relationships, the OR list, and time. CONCLUSIONS: Our findings offer possible solutions by elaborating on preparatory variability and considerations for residents, faculty, and programs to improve practice. As a first step, we suggest programs begin to engage in explicit dialogue and reflection with their residents, faculty, and residency program committees.

Association Between Indication for Descemet Stripping Automated Endothelial Keratoplasty and Rural Residency.

PURPOSE: Residing in rural locations can be a barrier to health care access. This study investigated the impact of residing in rural and small town (RST) areas on Descemet stripping automated endothelial keratoplasty (DSAEK) indications and outcomes in Atlantic Canada. METHODS: A retrospective cohort analysis examined consecutive DSAEKs performed in Nova Scotia between 2017 and 2020. Patient rurality was determined by the Statistical Area Classification system developed by Statistics Canada. Univariate and multivariate logistic regression models were used to assess for factors associated with DSAEK indication, including repeat keratoplasty, RST residence status, and travel time. RESULTS: Of 271 DSAEKs during the study period, 87 (32.1%) were performed on the eyes of RST residents. The median postoperative follow-up time was 1.6 years. Undergoing DSAEK for a previous failed keratoplasty was not associated with a higher odds of RST residency (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.19-1.16; P = 0.13) but was associated with travel time (OR, 0.78 for each increasing hour of travel; 95% CI, 0.61-0.99; P = 0.044). RST residency was not associated with the occurrence of graft failure (OR, 0.48; 95% CI, 0.17-1.17; P = 0.13). CONCLUSIONS: Residing in a rural area in Atlantic Canada was not associated with DSAEK graft failure. Repeat endothelial keratoplasty was associated with shorter travel time for corneal surgery but not rural residency status. Further research in this field could inform regional health strategies aimed at improving equity and accessibility to ophthalmology subspecialist care.

Nuclear translocation of the 1,25D3-MARRS (membrane associated rapid response to steroids) receptor protein and NFkappaB in differentiating NB4 leukemia cells.

1,25 Dihydroxyvitamin D(3) (1,25D(3)) primes NB4 promyelocytic leukemia cells to differentiate along the monocyte/macrophage lineage through a non-genomic mechanism. Here we show that NB4 cells express high levels of the recently identified membrane receptor for 1,25D(3), which is a distinct gene product from the classical nuclear vitamin D receptor. This 57 kDa protein, named 1,25D(3)-MARRS (Membrane Activated Rapid Response to Steroids)/ERp57/PIA3 appears to associate in a complex with the transcription factor, nuclear factor kappa B (NFkappaB). In unstimulated cells, 1,25D(3)-MARRS can be co-immunoprecipitated with antibodies directed at NFkappaB, and NFkappaB is co-precipitated when antibodies against 1,25D(3)-MARRS or ERp57 are used. Confocal microscopy and subcellular fractionation studies demonstrate that both 1,25D(3)-MARRS and NFkappaB begin translocating to the nucleus within minutes of co-stimulation with 1,25D(3) and phorbol ester. The predominant nuclear localization of both proteins precedes the expression of the monocyte/macrophage phenotype and suggests that this event may be critical to the differentiation pathway. This suggests a role for 1,25D(3)-MARRS in the nucleus as a regulator of gene expression. Here it may also regulate the activity of NFkappaB and other factors with which it may be interacting.

Peripheral Ulcerative Keratitis Secondary to Atypical Hemolytic Uremic Syndrome.

PURPOSE: To report a case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. METHODS: We report the case of a 76-year-old man who presented with bilateral aggressive peripheral ulcerative keratitis. Clinical examinations and investigations are reported from the patients' admission. RESULTS: The patient had an extended workup for autoimmune and infectious etiologies that all returned negative. The laboratory work in conjunction with renal biopsy and clinical symptoms were consistent with atypical hemolytic uremic syndrome. The patient was treated with systemic steroids for his peripheral ulcerative keratitis and underlying systemic disease. Corneal glueing and amniotic membrane grafting was also performed. CONCLUSIONS: To our knowledge, we report the first known case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. In cases where the standard workup is negative, this diagnosis should be considered because it can have significant systemic morbidity.