Axillary Surgery for Chemoresidual (ypN-Positive) Nodal Disease.

This cohort study using pooled data from 2 randomized clinical trials examines whether removing more lymph nodes with axillary lymph node dissection improved outcomes over sentinel lymph node biopsy when most patients received adjuvant radiation therapy or regional nodal irradiation.

Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. METHODS: We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). RESULTS: 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260 mL [95-463] versus 75 mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. CONCLUSION: Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.

Use of a hybrid-abdominal wound simulated patient in the ACS/ASE medical student simulation skills curriculum.

OBJECTIVE: We incorporated a hybrid-abdominal wound simulation to teach/assess the acquisition of three essential clinical skills in the ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum. METHOD: Third year students (N = 43) attended a workshop based on the ACS/ASE surgical skills curriculum for drain care/removal, staple removal and Steri-Strip application. Following a didactic session and demonstration using a simulated patient, student skill acquisition was assessed using the ACS/ASE module rating tool. Student interest/perceived usefulness of the workshop was evaluated using Keller's Motivational Survey. RESULTS: We used median scores to identify low proficiency (n = 20; scores 17-28) and high proficiency (n = 23; scores 29-35) groups. The high proficiency group was more knowledgeable, performed better drain care, had a higher global score and was more confident than the low proficiency group. The students rated the workshop highly based on the Keller's Motivational Survey. CONCLUSION: All students were proficient in the procedure tasks and communication skills and most felt that the course was beneficial. The ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum was successfully integrated into our third year surgical clerkship.

Mixed reality humans: evaluating behavior, usability, and acceptability.

This paper presents Mixed Reality Humans (MRHs), a new type of embodied agent enabling touch-driven communication. Affording touch between human and agent allows MRHs to simulate interpersonal scenarios in which touch is crucial. Two studies provide initial evaluation of user behavior with a MRH patient and the usability and acceptability of a MRH patient for practice and evaluation of medical students' clinical skills. In Study I (n=8) it was observed that students treated MRHs as social actors more than students in prior interactions with virtual human patients (n=27), and used interpersonal touch to comfort and reassure the MRH patient similarly to prior interactions with human patients (n=76). In the within-subjects Study II (n=11), medical students performed a clinical breast exam on each of a MRH and human patient. Participants performed equivalent exams with the MRH and human patients, demonstrating the usability of MRHs to evaluate students' exam skills. The acceptability of the MRH patient for practicing exam skills was high as students rated the experience as believable and educationally beneficial. Acceptability was improved from Study I to Study II due to an increase in the MRH's visual realism, demonstrating that visual realism is critical for simulation of specific interpersonal scenarios.

A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship.

BACKGROUND: We aimed to determine if an immersive virtual patient (VP) with a breast complaint and a breast mannequin could prepare third-year medical students for history-taking (HT) and clinical breast examination (CBE) on a real patient. METHODS: After standardized instruction in breast HT and CBE, students (n = 21) were randomized to either an interaction with a VP (experimental) or to no VP interaction (control) before seeing a real patient with a breast complaint. Participants completed baseline and exit surveys to assess confidence regarding their HT and CBE skills. RESULTS: Students reported greater confidence in their HT (Delta value = 1.05 +/- 1.28, P < .05) and CBE skills (Delta value = 1.14 +/- .91, P < .05) and less anxiety when performing a CBE (Delta value = -.76 +/- 1.10, P < .05). The VP intervention group had a significantly higher mean HT confidence than the control group at the conclusion of the study (4.27 +/- .47 vs 3.50 +/- .71, respectively, P < .05). CONCLUSIONS: A single interaction with a VP with a breast complaint and breast mannequin improves student confidence in breast HT during a surgery clerkship.

Do increased training requirements in gastrointestinal endoscopy and advanced laparoscopy necessitate a paradigm shift? A survey of program directors in surgery.

BACKGROUND: Many modifications to the traditional residency model contribute to the ongoing paradigm shift in surgical education; yet, the frequency and manner by which such changes occur at various institutions is less clear. To address this issue, our study examined the variability in endoscopy and laparoscopy training, the potential impact of new requirements, and opinions of Program Directors in Surgery (PDs). METHODS: A 22-item online survey was sent to 251 PDs in the United States. Appropriate parametric tests determined significance. RESULTS: In all, 105 (42%) PDs responded. No difference existed in response rates among university (56.2%), university-affiliated/community (30.5%), or community (13.3%) program types (p = 0.970). Surgeons alone (46.7%) conducted most endoscopy training with a trend toward multidisciplinary teams (43.8%). A combination of fellowship-trained minimally invasive surgeons and other surgeon types (66.7%) commonly provided laparoscopy training. For adequate endoscopy experience in the future, most PDs (74.3%) plan to require a formal flexible endoscopy rotation (p < 0.001). For laparoscopy, PDs intend for more minimally invasive surgery (59%) as well as colon and rectal surgery (53.4%) rotations (both p < 0.001). Respondents feel residents will perform diagnostic endoscopy (86.7%) and basic laparoscopy (100%) safely on graduation. Fewer PDs confirm graduates will safely practice therapeutic endoscopy (12.4%) and advanced laparoscopy (52.4%). PDs believe increased requirements for endoscopy and laparoscopy will improve procedural competency (79% and 92.4%, respectively) and strengthen the fields of surgical endoscopy and minimally invasive surgery (55.2% and 68.6%, respectively). Less believe new requirements necessitate redesign of cognitive and technical skills curricula (33.3% endoscopy, 28.6% laparoscopy; p = 0.018). A national surgical education curriculum should be a required component of resident training, according to 79% of PDs. CONCLUSIONS: PDs employ and may implement varied tools to meet the increased requirements in endoscopy and laparoscopy. With such variability in educational methodology, establishment of a national surgical education curriculum is very important to most PDs.

All-terrain vehicle trauma in the elderly: an analysis of a national database.

The elderly are a growing proportion of all-terrain (ATV) drivers. The purpose of this study was to determine if the outcomes of geriatric ATV trauma victims are different from those of their younger counterparts and if age is an independent predictor of mortality. ATV trauma cases in the United States reported to the National Trauma Data Bank between 1989 and 2003 comprised the study population. A logistic regression model was constructed with mortality as the outcome and age as the primary covariate of interest. A total of 6308 ATV-related traumas were reported to the National Trauma Data Bank during the study period. Geriatric victims presented with significantly higher systolic blood pressure (138.6 +/- 34.4 vs 131.4 +/- 24.8, P < 0.001) and had a significantly longer length of stay (8.3 +/- 11.4 vs 4.8 +/- 8.8, P < 0.001) and greater number of intensive care unit days (3.1 +/- 7.1 vs 1.3 +/- 4.0, P < 0.001). In a multivariate model, age older than 60 years was associated with increased risk of mortality (OR, 6.96; 95% CI, 3.75-12.92). Age older than 60 years is an independent predictor of mortality among ATV trauma cases. Improved training on the use of ATVs in this population and better safety features are warranted.

Medical student satisfaction using a virtual patient system to learn history-taking communication skills.

Virtual patients (VPs) have the potential to augment existing medical school curricula to teach history-taking and communication skills. A goal of our current efforts to study virtual characters in health professions education is to develop a system that can be independently accessed and thus user satisfaction is an important factor in how readily this technology will be adopted. Twenty-three medical students participated in a study in which they interviewed a virtual patient and were asked to rate the educational value of the experience. Despite some of the limitations in this developing technology, students were generally receptive to its use as an educational tool. Further enhancements to the system, including increased fidelity of the interaction and novel feedback mechanisms, should improve learner satisfaction with and adoption of the virtual patient system.

Survey of student education in surgery.

BACKGROUND: Few data exist comparing medical student surgical education programs across the US and Canada. We conducted a 30-question, Web-based survey of 142 medical schools in the US and Canada about the administration of undergraduate surgical education programs at their institutions. STUDY DESIGN: From October 2005 to January 2006, 142 Association of American Medical Colleges (AAMC) medical schools in the US and Canada were asked to complete a 30-item, Web-based questionnaire. Descriptive statistics were compiled for all responses and data were analyzed using Student's t-test. RESULTS: One hundred two medical schools responded to the survey (90 of 125 US and 12 of 17 Canadian schools, overall response rate,=72%). The majority of surgical clerkships have between 16 and 30 students rotating at a time through 2 to 4 teaching sites. The most frequent overall clerkship duration was 8 weeks, divided most frequently between a 4- to 6-week general surgery rotation and a 4-week subspecialty rotation. There was no consensus about what services constitute general surgery rotations, although the most common subspecialty rotations were urology (68%) and orthopaedics (66%). American medical schools were more likely to use the National Board of Medical Examiners (NBME) subject examination for student assessment (90.9% US versus 50.0% Canadian, p < 0.05); Canadian medical schools were more likely to use an Objective Structured Clinical Examination (69.2% Canadian versus 37.7% US, p < 0.05) and other written examinations (69.2% Canadian versus 37.7% US, p < 0.05). CONCLUSIONS: There is wide variation in the structure and administration of medical student surgical education programs in the US and Canada. These findings underscore the need for a clerkship directors committee and a national dialog about a core student curriculum to ensure consistency in the quality of student education in surgery.

Do medical students respond empathetically to a virtual patient?

BACKGROUND: Significant information exchange occurs between a doctor and patient through nonverbal communication such as gestures, body position, and eye gaze. In addition, empathy is an important trust-building element in a physician: patient relationship. Previous work validates the use of virtual patients (VP) to teach and assess content items related to history-taking and basic communication skills. The purpose of this study was to determine whether more complex communication skills, such as nonverbal behaviors and empathy, were similar when students interacted with a VP or standardized patient (SP). METHODS: Medical students (n = 84) at the University of Florida (UF) and the Medical College of Georgia (MCG) underwent a videotaped interview with either a SP or a highly interactive VP with abdominal pain. In the scenario, a life-sized VP was projected on the wall of an exam room in SP teaching and testing centers at both institutions. VP and SP scripted responses to student questions were identical. To prompt an empathetic response (ie, acknowledging the patients' feelings), during the interview the VP or SP stated "I am scared; can you help me?" Clinicians (n = 4) rated student videotapes with respect to nonverbal communication skills and empathetic behaviors using a Likert-type scale with anchored descriptors. RESULTS: Clinicians rated students interacting with SPs higher with respect to the nonverbal communication skills such as head nod (2.78 +/- .79 vs 1.94 +/- .44, P < .05), and body lean (2.97 +/- .94 vs 1.93 +/- .58, P < .05), level of immersion in the scenario (3.31 +/- .49 vs 2.26 +/- .52, P < .05), anxiety (1.16 +/- .31 vs 1.45 +/- .33, P < .05), attitude toward the patient (3.24 +/- .43 vs 2.89 +/- .36, P < .05), and asking clearer questions (3.06 +/- .32 vs 2.51 +/- .32, P < .05) compared to the VP group. The students in the SP group also had a higher empathy rating (2.75 +/- .86 vs 2.16 +/- .83, P < .05) and better overall rating (4.29 +/- 1.32 vs 3.24 +/- 1.06, P < .05) than the VP group. Empathy was positively correlated with the observed nonverbal communication behaviors. Eye contact was the most strongly correlated with empathy (r = .57, P < .001), followed by head nod (r = .55, P < .001) and body lean (r = .49, P < .001). CONCLUSIONS: Medical students demonstrate nonverbal communication behaviors and respond empathetically to a VP, although the quantity and quality of these behaviors were less than those exhibited in a similar SP scenario. Student empathy in response to the VP was less genuine and not as sincere as compared to the SP scenario. While we will never duplicate a real physician/patient interaction, virtual clinical scenarios could augment existing SP programs by providing a controllable, secure, and safe learning environment with the opportunity for repetitive practice.

Population immunity to measles in the United States, 1999.

To estimate population immunity, we examined measles immunity among residents of the United States in 1999 from serological and vaccine coverage surveys. For persons aged >or=20 years, serological data from the third National Health and Nutrition Examination Survey (1988-1994) were used. For persons <20 years of age, immunity was estimated from results of the National Immunization Survey (1994-1998), state surveys of school entrants (1990-2000), and vaccine coverage surveys of adolescents (1997). To estimate immunity from vaccine coverage data, 95% vaccine efficacy was used for recipients of a single dose at >or=12 years of age and 99% vaccine efficacy was used for those with failure of a first dose who were revaccinated. Overall, calculated population immunity was found to be 93%. Although there was not much variation in immunity by region and state, in some large urban centers immunity among preschool-aged children was as low as 86%. Overall, geographic- and age-specific estimates of a high population immunity support the epidemiological evidence that measles disease is no longer endemic in the United States.

Adolescent immunizations. are we ready for a new wave?

CONTEXT: Factors associated with vaccination coverage rates for the 20% of U.S. adolescents enrolled in managed care organizations (MCOs) are not known. OBJECTIVES: To examine recent trends in receipt of two doses of measles-mumps-rubella (MMR2) and three doses of hepatitis B (Hep B3) among U.S. adolescents enrolled in managed care organizations (MCOs); to determine whether specific characteristics of MCOs are associated with higher vaccination rates; and to assess the impact of state middle school immunization requirements on these rates. DESIGN: Longitudinal (1996-1999) and cross-sectional (1999) analyses of National Committee for Quality Assurance (NCQA) data to estimate adolescent vaccination coverage rates for MMR2 and Hep B3. In 2002, using 1999 data only, a cross-sectional analysis examined the relationship of specific plan characteristics and state immunization laws with immunization coverage. MAIN OUTCOME MEASURES: Percentage of 13 year olds in MCOs with documented receipt of MMR2 and Hep B3. RESULTS: From 1996 to 1999, MMR2 rates increased from 56% to 64%, and from 1997 to 1999, Hep B3 rates increased from 23% to 38%. By 1999, higher rates for both vaccines had been achieved in larger plans (p<0.001 and p<0.003 for MMR2 and Hep B3, respectively), those with the highest NCQA accreditation status (p<0.003), those in New England (p<0.001), and those in states with middle school immunization requirements (p<0.001). CONCLUSIONS: Despite encouraging increases, adolescent immunization rates are significantly below the Healthy People 2010 goal of 90%. State laws and accreditation incentives are effective. Research is needed to identify additional interventions to increase vaccination coverage in the adolescent population.

Occupational exposures and risk of hepatitis B virus infection among public safety workers.

We conducted a questionnaire and seroprevalence survey to determine the frequency and type of occupational exposures (OEs) and the risk of hepatitis B virus (HBV) infection experienced by public safety workers (PSWs). Of the 2910 PSWs who completed the survey, 6.8% reported at least one OE in the previous 6 months, including needlestick (1.0%), being cut with a contaminated object (2.8%), mucous membrance exposure to blood (0.9%), and being bitten by a human (3.5%). The rate of OE varied by occupation with 2.7% of firefighters, 3.2% of sheriff officers, 6.6% of corrections officers, and 7.4% of police officers reporting > or = 1 OE (P < 0.001). The HBV infection prevalence was 8.6%, and after adjustment for age and race, it was comparable to the overall US prevalence and did not vary by occupation. By multivariate analysis, HBV infection was not associated with any OEs, but it was associated with older age, being nonwhite, and a previous history of a sexually transmitted disease. This study demonstrated that although OEs are not uncommon among PSWs, HBV infection was more likely to be associated with nonoccupational risk factors. Administration of hepatitis B vaccine to PSWs early in their careers will prevent HBV infection associated with occupational and non-OEs.