Educational Value of Surgical Residents Operating as Teaching Assistant.

OBJECTIVE: To assess the educational of value of teaching assistant (TA) cases from the perspectives of attending, chief resident, and junior resident. We hypothesized the greatest educational value of TA cases would be for chief residents more so than other team members. DESIGN: A prospective survey was designed and collected for TA cases separately from attendings, chief residents, and junior residents to assess operative details and educational value. The study period ran from August 2021 through December 2022. Qualitative and quantitative analysis was undertaken to compare answers and discover themes in the free-text responses of attendings and residents. SETTING: Single center, tertiary care institution, Maine Medical Center, Department of Surgery, Portland, ME PARTICIPANTS: Sixty-nine teaching assistant cases were captured from a total of 117 completed surveys that were completed by 44 chief residents, 49 junior residents, 22 attendings (n = 22) and 2 APPs. RESULTS: A wide variety of TA cases were included in the study with the most common reason for performing a TA case being resident request 68%. Operative complexity was most commonly rated easiest third (50%) and middle third (41%) of overall cases. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time. Attendings reported learning something about the resident's skills that they were not expecting in 59% of the cases. Thematic analysis: attendings focused on the steps of the procedure, including the technical aspects, particularly regarding opening while residents largely focused on communication and preparation. CONCLUSIONS: Teaching assistant cases seem to have more educational value for chief and junior residents than attendings. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time.

Barriers and facilitators to diabetes screening and prevention after a pregnancy complicated by gestational diabetes.

OBJECTIVE: Gestational diabetes mellitus (GDM) is increasing in the United States, with higher rates among minoritized racial and ethnic populations and lower income populations. GDM increases risk for type 2 diabetes (T2DM), and postpartum diabetes screening and prevention are imperative. This qualitative study examines barriers and facilitators to postpartum T2DM screening and prevention among non-privately insured individuals with a history of GDM in a state prior to Medicaid expansion. METHODS: Thirty-six non-privately insured women with a history of GDM completed semi-structured interviews. Four focus groups and seven interviews were conducted with 30 nurse practitioners, physicians, physician assistants, nurses and registered dietitians from Federally Qualified Health Centers in St. Louis, MO. Interviews and focus groups were audio-recorded and transcribed. Data were analyzed using an integrative thematic analysis informed by the socio-ecological model. RESULTS: Barriers and facilitators to T2DM screening and prevention occur across multiple environments (society, healthcare system, interpersonal, and individual). Societal barriers include insurance issues, unemployment, and lack of transportation, childcare, safe housing, and healthy food access, while facilitators include government sponsored programs and community organizations. Healthcare system barriers include care fragmentation, scheduling policies and time constraints while facilitators include care coordination, pregnancy support groups, and education materials. Interpersonal barriers include negative care experiences, cultural differences, communication challenges, competing priorities, and lack of a social support network, while facilitators include family and friend support and positive care experiences. Individual barriers include health complications and unhealthy food and exercise patterns, while facilitators include child wellbeing, empowered attitudes and healthy food and exercise patterns. CONCLUSIONS: The socioecological model highlights the societal and systemic determinants that encompass individual and interpersonal factors affecting postpartum T2DM screening and prevention. This framework can inform multi-level interventions to increase postpartum T2DM screening and prevention in this high-risk population, including policy changes to alleviate higher-level barriers.

Strategies to Achieve Breast Health Equity in the St. Louis Region and Beyond over 15+ Years.

Community-based participatory strategies are a promising approach to addressing disparities in community health outcomes. This paper details the efforts of Siteman Cancer Center to achieve breast health equity over the past 15+ years. We begin by describing the activities and successes arising from our breast health community partnerships including identifying priorities, developing recommendations, and implementing patient navigation services to advance breast health. This system-wide coordinated navigation approach that includes primary and specialty care providers helped to increase potential impact on reducing breast health disparities by expediting care, increasing care efficiency, and standardizing referral procedures across systems for all women including those who are uninsured and underinsured. We also discuss a mobile mammography unit that has been deployed to serve women living in both urban and rural regions. The van reached a particularly vulnerable population that was mostly poor, uninsured, and with limited educational backgrounds regardless of their zip code of service. This work shows that collaborations between academic and community partners have resulted in decreased late stage at diagnosis and improved access to mammography. Furthermore, we offer lessons learned and recommendations that may be applicable to other communities.

Understanding Gestational Diabetes, Future Diabetes Risk, and Diabetes Prevention: A Qualitative Study of Patient, Provider, and Staff Perspectives.

Gestational diabetes mellitus (GDM) increases type 2 diabetes risk; however, postpartum diabetes screening rates are low. Using semi-structured interviews and focus groups, this study investigates the understanding of GDM and its relationship to future diabetes risk and diabetes prevention among patients with public or no insurance (n = 36), health care providers (n = 21), and clinic staff (n = 9) from Federally Qualified Health Centers. Five main themes emerged: 1) general understanding of GDM diagnosis with focus on neonatal complications; 2) variable recall of diet, exercise, and weight recommendations; 3) overwhelming medication and self-monitoring routines; 4) short-term focus of type 2 diabetes risk and screening; and 5) limited understanding of all options for diabetes prevention. The results may inform diabetes screening and prevention interventions in primary care settings.

Evaluating Birth Outcomes From a Community-Based Pregnancy Support Program for Refugee Women in Georgia.

Refugee women face numerous and unique barriers to sexual and reproductive healthcare and can experience worse pregnancy-related outcomes compared with U.S.-born and other immigrant women. Community-based, culturally tailored programs like Embrace Refugee Birth Support may improve refugee access to healthcare and health outcomes, but empirical study is needed to evaluate programmatic benefits. This community-engaged research study is led by the Georgia Doula Access Working Group, including a partnership between academic researchers, Emory Decatur Hospital nurses, and Embrace. We analyzed hospital clinical records (N = 9,136) from 2016 to 2018 to assess pregnancy-related outcomes of Embrace participants (n = 113) and a comparison group of women from the same community and racial/ethnic backgrounds (n = 9,023). We controlled for race, language, maternal age, parity, insurance status, preeclampsia, and diabetes. Embrace participation was significantly associated with 48% lower odds of labor induction (OR = 0.52, p = 0.025) and 65% higher odds of exclusive breastfeeding intentions (OR = 1.65, p = 0.028). Embrace showed positive but non-significant trends for reduced cesarean delivery (OR = 0.83, p = 0.411), higher full-term gestational age (OR = 1.49, p = 0.329), and reduced low birthweight (OR = 0.77, p = 0.55). We conclude that community-based, culturally tailored pregnancy support programs like Embrace can meet the complex needs of refugee women. Additionally, community-engaged, cross-sector research approaches could ensure the inclusion of both community and clinical perspectives in research design, implementation, and dissemination.

Differential diagnosis of calcified nodules from a medieval Székely woman in Transylvania.

OBJECTIVE: To differentially diagnose two calcified objects found with the well-preserved and nearly complete skeletal remains excavated in June 2012 by the Haáz Rezso Múzeum in Odorheiu Secuiesc, Romania. MATERIAL: Two objects measuring 25.55 × 18.23 mm and 17.62 × 16.38 mm found with the skeletal remains of a probable female approximately 25-35 years old at the time of death. METHODS: Analysis utilized X-ray, SEM, EDS, CT scanning, and gross morphology to assess pathological conditions with calcification as a common sign. RESULTS: Multiple analyses of the objects revealed two roughened ovoid nodes with internal hollows and openings. Elemental analysis indicated an organic origin, likely representing calcified soft tissue. CONCLUSIONS: Differential diagnosis determined the calcified nodules to be consistent with calcified tumors, and most consistent with a calcified leiomyoma with cystic degeneration, potentially uterine. SIGNIFICANCE: The identification of the calcified nodules as most consistent with calcified uterine leiomyomas adds to the paucity of paleopathological literature on calcified leiomyomas and calcified tumors more broadly. It also allows for an important discussion of the health of women in medieval Transylvania. LIMITATIONS: Interpretation would be aided if a more precise origination within the body was known. Careful excavation and improved recognition of organic objects is necessary for a more definite diagnosis. SUGGESTIONS FOR FURTHER RESEARCH: Soft tissue calcifications are a common process in a wide variety of diseases and can arise in all areas of the body. Pathological calcifications are relatively common in modern contexts, but remain rare in paleopathological literature.

Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model.

BACKGROUND: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. METHODS: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann-Whitney U test. Values are represented as average myofascial medialization in centimeters. RESULTS: Following MLL an average of 5.0 ± 0.9 cm (range 3.4-6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3-10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6-12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. CONCLUSIONS: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen.

Laparoscopic ventral hernia repair with and without defect closure: comparative analysis of a single-institution experience with 783 patients.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) has gained popularity, since it can decrease the incidence of surgical site complications while providing similar recurrence rates as open repairs. The role of defect closure in LVHR has been a subject of controversy and has not been fully elucidated. We aimed to compare outcomes of LVHR with and without defect closure in a contemporary cohort. METHODS: Single-institution retrospective review of consecutive adults undergoes elective LVHR for 2-8 cm defects. Demographics, perioperative, and post-operative data were included for analysis. Surgical site events (SSE), surgical site infection (SSI), and recurrence were the main measured outcomes. Abdominal CT scan was used to differentiate true recurrence from pseudo-recurrence. RESULTS: A total of 783 patients were analyzed. 222 of them had their defects closed (DC), while the remaining 561 defects were not closed (NC) at the discretion/routine of the operating surgeon. Patients were slightly older in the non-closure group, while those in the defect closure group had a significantly higher BMI. There were no other differences in demographics between groups. After a mean follow-up of 12.1 months, the incidence of surgical site events (3.6 vs 14.9%, p < 0.0001) and seromas (0.4 vs 11.5%, p < 0.0001) was significantly lower in the defect closure group. Objectively confirmed recurrences were also significantly lower in the DC group (5.4 vs 14.2%, p = 0.003). CONCLUSIONS: In our experience, the addition of defect closure can reduce the incidence of surgical site events, seroma, and hernia recurrence after LVHR. We advocate for routine closure of defects when laparoscopic repair is chosen for small-to-mid-sized ventral hernias.

Health care worker perceptions toward computerized clinical decision support tools for Clostridium difficile infection reduction: A qualitative study at 2 hospitals.

BACKGROUND: Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Computerized clinical decision support (CCDS) tools can aid process improvement in infection prevention and antibiotic stewardship, but implementation and health care workers (HCWs) uptake of these tools is often variable. The objective of this study was to describe HCWs' perceptions of barriers and facilitators related to uptake of CCDS tools as part of a CDI reduction bundle. METHODS: We conducted a qualitative study among HCWs at 2 acute care hospitals in Maryland. Semi-structured interviews and structured surveys were completed by HCWs to evaluate their perception to CCDS tools at 2 different stages: predevelopment and preimplementation. Emergent themes and patterns in the data were identified and condensed. RESULTS: Gaps in CDI-related knowledge and in communication between HCWs were identified throughout the evaluation. HCWs agreed on the potential of the tools to improve CDI diagnosis, prevention, and control. An important barrier for uptake was the perceived loss of autonomy and clinical judgment, whereas standardization and error reduction were perceived advantages. CONCLUSIONS: These observations shaped the development and implementation of the CDI reduction bundle. Qualitative findings can provide valuable contextual information during the development stages of CCDS tools in infection prevention and antibiotic stewardship.

Inguinal Hernia: Mastering the Anatomy.

The success of an inguinal hernia repair is defined by the permanence of the operation while creating the fewest complications at minimal cost and allowing patients an early return to activity. This success relies and depends on the surgeon's knowledge and understanding of groin anatomy and physiology. This article reviews relevant anatomy to inguinal hernia repair and technical steps to open tissue and mesh repairs as well as minimally invasive approaches.

Silicone Hydrogel and Rigid Gas-Permeable Scleral Lens Tear Exchange.

OBJECTIVES: To quantify tear elimination rate (ER) underneath silicone hydrogel (Si-Hy) and scleral gas permeable (GP) contact lenses (CLs). METHODS: Subjects successfully using either well-fitting soft Si-Hy CLs or scleral GP CLs were recruited. Most scleral GP CL wearers had irregular corneas (e.g., keratoconus). An objective fluorometer measured decay of fluorescein isothiocyanate dextran dye signal (70 kD MW) from which the tear ER in %/min was calculated. For GP scleral lenses, the ER was determined for both the initial settling period and the 30- to 60-min period, and without lenses. All ERs were calculated from 5 to 30 min to avoid reflex tearing effects. RESULTS: Fourteen soft Si-Hy CL and 12 scleral GP CL wearers completed the study. The ER for the scleral GP CL wearers averaged 0.57 (±0.6) %/min for the 0- to 30-min and 0.42 (±0.5) %/min for the 30- to 60-min period (P=0.515). Non-CL wear tear ER in these same subjects averaged 34.17 (±15.9) %/min and was significantly different versus both scleral GP wear periods (both P values <0.001). The ER for the soft Si-Hy CL wearers, 5 to 30 min, averaged 6.09 (±2.8) %/min. CONCLUSIONS: Our data demonstrate significantly less ER in well-fit scleral GP CL wearers compared with soft Si-Hy CL wearers for both the settling and longer wear periods (both P values <0.001). Moreover, slightly greater tear exchange was observed during the scleral GP CL settling period than later, which may reflect a change over time in tear vault thickness.

Stapled Transabdominal Ostomy Reinforcement with retromuscular mesh (STORRM): Technical details and early outcomes of a novel approach for retromuscular repair of parastomal hernias.

BACKGROUND: Parastomal hernia repair (PHR) remains a challenge with no optimal repair technique. During retromuscular hernia repair, traversing the stomal conduit through the abdominal wall can result in angulation and compression. Widening of traditional cruciate incisions in mesh and/or fascia likely contributes to recurrences. To address these pitfalls, the Stapled Transabdominal Ostomy Reinforcement with Retromuscular Mesh (STORRM) technique utilizing a circular stapler was developed. METHODS: A prospective registry of consecutive patients undergoing STORRM was analyzed. We characterized demographics, hernia characteristics, and perioperative results. Primary outcomes were complications, surgical site events (SSEs) and hernia recurrence. RESULTS: 12 patients underwent PHR with STORRM; mean age 64 and BMI 36 kg/m2. Synthetic mesh was used in 92% of patients. We observed two (17%) SSEs, one case of cellulitis and one organ space infection. With mean 12.8-month follow-up, we documented two recurrences. CONCLUSIONS: STORRM represents a safe method to repair parastomal hernias. The unified aperture with stapled reinforcement results in reproducible repairs, minimizing intestinal angulation associated with traditional stoma passage. Early outcomes evidenced minimal complications and favorable recurrence rate.

Hematopoietic-to-mesenchymal transition of adipose tissue macrophages is regulated by integrin ß1 and fabricated fibrin matrices.

Some bona fide adult adipocytes arise de novo from a bone marrow-derived myeloid lineage. These studies further demonstrate that adipose tissue stroma contains a resident population of myeloid cells capable of adipocyte and multilineage mesenchymal differentiation. These resident myeloid cells lack hematopoietic markers and express mesenchymal and progenitor cell markers. Because bone marrow mesenchymal progenitor cells have not been shown to enter the circulation, we hypothesized that myeloid cells acquire mesenchymal differentiation capacity in adipose tissue. We fabricated a 3-dimensional fibrin matrix culture system to define the adipose differentiation potential of adipose tissue-resident myeloid subpopulations, including macrophages, granulocytes and dendritic cells. Our data show that multilineage mesenchymal potential was limited to adipose tissue macrophages, characterized by the acquisition of adipocyte, osteoblast, chondrocyte and skeletal muscle myocyte phenotypes. Fibrin hydrogel matrices stimulated macrophage loss of hematopoietic cell lineage determinants and the expression of mesenchymal and progenitor cell markers, including integrin ß1. Ablation of integrin ß1 in macrophages inhibited adipocyte specification. Therefore, some bona fide adipocytes are specifically derived from adipose tissue-resident macrophages via an integrin ß1-dependent hematopoietic-to-mesenchymal transition, whereby they become capable of multipotent mesenchymal differentiation. The requirement for integrin ß1 highlights this molecule as a potential target for controlling the production of marrow-derived adipocytes and their contribution to adipose tissue development and function.

POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia.

BACKGROUND: Achalasia is a rare motility disorder of the esophagus. Treatment is palliative with the goal of symptom remission and slowing the progression of the disease. Treatment options include per oral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LM) and endoscopic treatments such as pneumatic dilation (PD) and botulinum toxin type A injections (BI). We evaluate the economics and cost-effectiveness of treating achalasia. METHODS: We performed cost analysis for POEM, LM, PD and BI at our institution from 2011 to 2015. Cost of LM was set to 1, and other procedures are presented as percentage change. Cost-effectiveness was calculated based on cost, number of interventions required for optimal results for dilations and injections and efficacy reported in the current literature. Incremental cost-effectiveness ratio was calculated by a cost-utility analysis using quality-adjusted life year gained, defined as a symptom-free year in a patient with achalasia. RESULTS: Average number of interventions required was 2.3 dilations or two injections for efficacies of 80 and 61 %, respectively. POEM cost 1.058 times the cost of LM, and PD and BI cost 0.559 and 0.448 times the cost of LM. Annual cost per cure over a period of 4 years for POEM, and LM were consistently equivalent, trending the same as PD although this has a lower initial cost. The cost per cure of BI remains stable over 3 years and then doubles. CONCLUSION: The cost-effectiveness of POEM and LM is equivalent. Myotomy, either surgical or endoscopic, is more cost-effective than BI due to high failure rates of the economical intervention. When treatment is being considered BI should be utilized in patients with less than 2-year life expectancy. Pneumatic dilations are cost-effective and are an acceptable approach to treatment of achalasia, although myotomy has a lower relapse rate and is cost-effective compared to PD after 2 years.

Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction.

BACKGROUND: Despite patient risk factors such as diabetes and obesity, contamination during surgery remains a significant cause of infections and subsequent wound morbidity. Pressurized pulse lavage (PPL) has been utilized as a method to reduce bacterial bioburden with promising results in many fields. Although existing methods of lavage have been utilized during abdominal operations, no studies have examined the use of PPL during complex hernia repair. METHODS: Patients undergoing abdominal wall reconstruction (AWR) in clean-contaminated or contaminated fields with antibiotic PPL, from January 2012 to May 2013, were prospectively evaluated. Primary outcome measures studied were conversion of retrorectus space culture from positive to negative after PPL and 30-day surgical site infection (SSI) rate. RESULTS: A total of 56 patients underwent AWR, with 44 patients (78.6 %) having clean-contaminated fields and 12 patients (21.4 %) having contaminated ones. Twenty-two patients (39.3 %) had positive pre-PPL cultures, 18 of which (81.8 %) converted to negative cultures after PPL. Eleven patients (19.6 %) developed SSIs. Those with persistently positive cultures after PPL had the highest rate of SSI, where two out of four patients (50.0 %) developed an SSI. Contrastingly, only 5 of 18 patients (27.8 %) who converted from a positive to negative culture after PPL developed an SSI. CONCLUSION: Our findings demonstrate that antibiotic PPL is an effective method to reduce bacterial bioburden during AWR in clean-contaminated and contaminated fields. While complete conversion and eradication of SSI were not achieved, we believe that PPL may be a useful adjunct to standard operative asepsis in preventing prosthetic contamination during contaminated AWR.

De novo generation of adipocytes from circulating progenitor cells in mouse and human adipose tissue.

White adipocytes in adults are typically derived from tissue resident mesenchymal progenitors. The recent identification of de novo production of adipocytes from bone marrow progenitor-derived cells in mice challenges this paradigm and indicates an alternative lineage specification that adipocytes exist. We hypothesized that alternative lineage specification of white adipocytes is also present in human adipose tissue. Bone marrow from transgenic mice in which luciferase expression is governed by the adipocyte-restricted adiponectin gene promoter was adoptively transferred to wild-type recipient mice. Light emission was quantitated in recipients by in vivo imaging and direct enzyme assay. Adipocytes were also obtained from human recipients of hematopoietic stem cell transplantation. DNA was isolated, and microsatellite polymorphisms were exploited to quantify donor/recipient chimerism. Luciferase emission was detected from major fat depots of transplanted mice. No light emission was observed from intestines, liver, or lungs. Up to 35% of adipocytes in humans were generated from donor marrow cells in the absence of cell fusion. Nontransplanted mice and stromal-vascular fraction samples were used as negative and positive controls for the mouse and human experiments, respectively. This study provides evidence for a nontissue resident origin of an adipocyte subpopulation in both mice and humans.

Analysis and isolation of adipocytes by flow cytometry.

Analysis and isolation of adipocytes via flow cytometry is particularly useful to study their biology. However, the adoption of this technology has often been hampered by the presence of stromal/vascular cells in adipocyte fractions prepared from collagenase-digested adipose tissue. Here, we describe a multistep staining method and gating strategy that effectively excludes stromal contaminants. Initially, we set a gate optimized to the size and internal complexity of adipocytes. Exclusion of cell aggregates is then performed based on fluorescence of a nuclear stain followed by positive selection to collect only those cell events containing lipid droplets. Lastly, negative selection of cells expressing stromal or vascular lineage markers removes any remaining stromal contaminants. These procedures are applicable to simple analysis of adipocytes and their subcellular constituents by flow cytometry as well as isolation of adipocytes by flow sorting.

An inter-rater reliability study for the rorschach performance assessment system.

Based on available research findings, the Rorschach performance assessment system (Meyer, Viglione, Mihura, Erard, & Erdberg, 2011 ) was recently developed in an attempt to ground the administration, coding, and interpretation of the Rorschach in its evidence base, improve its normative foundation, integrate international findings, reduce examiner variability, and increase utility. This study sought to establish inter-rater reliability for the coding decisions in this new system. We randomly selected 50 Rorschach records from ongoing research projects using R-Optimized administration. The records were administered by 16 examiners and came from a diverse sample in terms of age, sex, ethnicity, educational background, and patient status. Results demonstrated a mean intraclass correlation of .88 and median of .92. Overall, the findings indicate good to excellent inter-rater reliability for the great majority of codes and are consistent with previous findings of strong inter-rater reliability for alternative Rorschach systems and scores.