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Montgomery KB, Mellinger JD, McLeod MC, Jones A, Zmijewski P, Sarosi GA, Brasel KJ, Klingensmith ME, Minter RM, Buyske J, Lindeman B. Decision-Making Confidence of Clinical Competency Committees for Entrustable Professional Activities. JAMA Surg 2024:2818486. [PMID: 38717759 PMCID: PMC11079788 DOI: 10.1001/jamasurg.2024.0809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/02/2024] [Indexed: 05/12/2024]
Abstract
Importance A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs' clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known. Objective To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions. Design, Setting, and Participants This cohort study used deidentified data from the EPA Pilot Study, with participating sites at 28 general surgery residency programs, prospectively collected from July 1, 2018, to June 30, 2020. Data were analyzed from September 27, 2022, to February 15, 2023. Exposure Microassessments of resident entrustment for pilot EPAs (gallbladder disease, inguinal hernia, right lower quadrant pain, trauma, and consultation) collected within the course of routine clinical care across four 6-month study cycles. Summative entrustment ratings were then determined by program CCCs for each study cycle. Main Outcomes and Measures The primary outcome was CCC decision-making confidence rating (high, moderate, slight, or no confidence) for summative entrustment decisions, with a secondary outcome of number of EPA microassessments received per summative entrustment decision. Bivariate tests and mixed-effects regression modeling were used to evaluate factors associated with CCC confidence. Results Among 565 residents receiving at least 1 EPA microassessment, 1765 summative entrustment decisions were reported. Overall, 72.5% (1279 of 1765) of summative entrustment decisions were made with moderate or high confidence. Confidence ratings increased with increasing mean number of EPA microassessments, with 1.7 (95% CI, 1.4-2.0) at no confidence, 1.9 (95% CI, 1.7-2.1) at slight confidence, 2.9 (95% CI, 2.6-3.2) at moderate confidence, and 4.1 (95% CI, 3.8-4.4) at high confidence. Increasing number of EPA microassessments was associated with increased likelihood of higher CCC confidence for all except 1 EPA phase after controlling for program effects (odds ratio range: 1.21 [95% CI, 1.07-1.37] for intraoperative EPA-4 to 2.93 [95% CI, 1.64-5.85] for postoperative EPA-2); for preoperative EPA-3, there was no association. Conclusions and Relevance In this cohort study, the CCC confidence in EPA summative entrustment decisions increased as the number of EPA microassessments increased, and CCCs endorsed moderate to high confidence in most entrustment decisions. These findings provide early validity evidence for this novel assessment framework and may inform program practices as EPAs are implemented nationally.
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Affiliation(s)
| | - John D. Mellinger
- American Board of Surgery, Philadelphia, Pennsylvania
- Department of Surgery, Southern Illinois University, Springfield
| | | | - Andrew Jones
- American Board of Surgery, Philadelphia, Pennsylvania
| | | | | | - Karen J. Brasel
- Department of Surgery, Oregon Health & Science University, Portland
| | - Mary E. Klingensmith
- American Board of Surgery, Philadelphia, Pennsylvania
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | | | - Jo Buyske
- American Board of Surgery, Philadelphia, Pennsylvania
- Department of Surgery, University of Pennsylvania, Philadelphia
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Filiberto AC, Loftus TJ, Crippen CJ, Hu D, Balch JA, Efron PA, Sarosi GA, Upchurch GR. Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention. J Am Coll Surg 2024; 238:404-413. [PMID: 38224109 DOI: 10.1097/xcs.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs. STUDY DESIGN An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes. For inpatient procedures, predicted mortality and length of stay were used to calculate observed-to-expected ratios and value of care using validated equations. For commonly performed (1 or more per week) procedures, the pipeline generated figures illustrating individual surgeon performance vs peers, costs for each surgeon performing each case type, and control charts identifying out-of-control cases and surgeons with more than 90th percentile costs, which were shared with surgeons and division chiefs alongside guidance for modifying case-specific supply instructions to operating room nurses and technicians. RESULTS Preintervention control (1,064 cases for 7 months) and postintervention (307 cases for 2 months) cohorts had similar baseline characteristics across all 16 commonly performed procedures. Median costs per case were lower in the intervention cohort ($811 [$525 to $1,367] vs controls: $1,080 [$603 to $1,574], p < 0.001), as was the incidence of out-of-control cases (19 (6.2%) vs 110 (10.3%), p = 0.03). Duration of surgery, length of stay, discharge disposition, and 30-day mortality and readmission rates were similar between cohorts. Value of care was higher in the intervention cohort (1.1 [0.1 to 1.5] vs 1.0 [0.2 to 1.4], p = 0.04). Pipeline runtime was 16:07. CONCLUSIONS An automated, sustainable quality improvement intervention was associated with decreased operating room supply costs and increased value of care.
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Affiliation(s)
- Amanda C Filiberto
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Tyler J Loftus
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL (Loftus, Hu)
| | - Cristina J Crippen
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Die Hu
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL (Loftus, Hu)
| | - Jeremy A Balch
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Philip A Efron
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - George A Sarosi
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Gilbert R Upchurch
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
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Montgomery KB, Mellinger JD, Jones A, McLeod MC, Zmijewski P, Sarosi GA, Brasel KJ, Klingensmith ME, Minter RM, Buyske J, Lindeman B. Validity of Entrustable Professional Activities in a National Sample of General Surgery Residency Programs. J Am Coll Surg 2024; 238:376-384. [PMID: 38224150 PMCID: PMC10942265 DOI: 10.1097/xcs.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones. STUDY DESIGN Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings. RESULTS A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455). CONCLUSIONS Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees.
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Affiliation(s)
| | - John D Mellinger
- American Board of Surgery, Philadelphia, PA
- Department of Surgery, Southern Illinois University, Springfield, IL
| | | | - M Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - George A Sarosi
- Department of Surgery, University of Florida, Gainesville, FL
| | - Karen J Brasel
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Mary E Klingensmith
- Accreditation Council for Graduate Medical Education, Chicago, IL
- Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | | | - Jo Buyske
- American Board of Surgery, Philadelphia, PA
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Brasel KJ, Lindeman B, Jones A, Sarosi GA, Minter R, Klingensmith ME, Whiting J, Borgstrom D, Buyske J, Mellinger JD. Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study. Ann Surg 2023; 278:578-586. [PMID: 37436883 DOI: 10.1097/sla.0000000000005991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. METHODS 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. RESULTS Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. CONCLUSIONS These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.
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Affiliation(s)
- Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | | | - George A Sarosi
- Department of Surgery, University of Florida, Gainesville, FL
| | - Rebecca Minter
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Mary E Klingensmith
- Accreditation Council for Graduate Medical Education, Chicago, IL
- Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - James Whiting
- Department of Surgery, Maine Medical Center, Portland, ME
| | - David Borgstrom
- Department of Surgery, University of West Virginia, Morgantown, WV
| | - Jo Buyske
- American Board of Surgery, Philadelphia, PA
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5
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Filiberto AC, Nyren MQ, Underwood PW, Balch JA, Abbott KL, Efron PA, Sarosi GA, Bihorac A, Upchurch GR, Loftus TJ. Resource use for cholecystectomy with versus without cholangiography: A multicenter, propensity-matched analysis. Surgery 2023; 174:152-158. [PMID: 37188579 DOI: 10.1016/j.surg.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/23/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intraoperative cholangiography may allow for earlier identification of common bile duct injury and choledocholithiasis. The role of intraoperative cholangiography in decreasing resource use related to biliary pathology remains unclear. This study tests the null hypothesis that there is no difference in resource use for patients undergoing laparoscopic cholecystectomy with versus without intraoperative cholangiography. METHODS This retrospective, longitudinal cohort study included 3,151 patients who underwent laparoscopic cholecystectomy at 3 university hospitals. To minimize differences in baseline characteristics while maintaining adequate statistical power, propensity scores were used to match 830 patients who underwent intraoperative cholangiography at surgeon discretion and 795 patients who underwent cholecystectomy without intraoperative cholangiography. Primary outcomes were the incidence of postoperative endoscopic retrograde cholangiography, the interval between surgery and endoscopic retrograde cholangiography, and total direct costs. RESULTS In the propensity-matched analysis, the intraoperative cholangiography and no intraoperative cholangiography cohorts had similar age, comorbidities, American Society of Anesthesiologists Sequential Organ Failure Assessment scores, and total/direct bilirubin ratios. The intraoperative cholangiography cohort had a lower postoperative endoscopic retrograde cholangiography (2.4% vs 4.3%; P = .04), a shorter interval between cholecystectomy and endoscopic retrograde cholangiography (2.5 [1.0-17.8] vs 4.5 [2.0-9.5] days; P = .04), and shorter length of stay (0.3 [0.2-1.5] vs 1.4 [0.3-3.2] days; P < .001). Patients undergoing intraoperative cholangiography had lower total direct costs ($4.0K [3.6K-5.4K] vs $8.1K [4.9K-13.0K]; P < .001). There were no differences in 30-day or 1-year mortality among the cohorts. CONCLUSION Compared with laparoscopic cholecystectomy without intraoperative cholangiography, cholecystectomy with intraoperative cholangiography was associated with decreased resource use, which was primarily attributable to decreased incidence and the earlier timing of postoperative endoscopic retrograde cholangiography.
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Affiliation(s)
| | - Molly Q Nyren
- College of Medicine, University of Florida Health, Gainesville, FL. https://twitter.com/Molly_Nyren
| | - Patrick W Underwood
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/P_Underwood21
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/balchja
| | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL. https://twitter.com/AzraBihorac
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/gru6n
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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6
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Barrios EL, Polcz VE, Hensley SE, Sarosi GA, Mohr AM, Loftus TJ, Upchurch GR, Sumfest JM, Efron PA, Dunleavy K, Bible L, Terracina KP, Al-Mansour MR, Gravina N. A narrative review of ergonomic problems, principles, and potential solutions in surgical operations. Surgery 2023:S0039-6060(23)00177-0. [PMID: 37202309 DOI: 10.1016/j.surg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions. METHODS pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature. RESULTS Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation. CONCLUSION Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons.
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Affiliation(s)
- Evan L Barrios
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Valerie E Polcz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Sara E Hensley
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Jill M Sumfest
- Gatorcare Health Management Corporation, University of Florida, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Kim Dunleavy
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | - Letitia Bible
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Krista P Terracina
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Mazen R Al-Mansour
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Nicole Gravina
- Department of Psychology, University of Florida, Gainesville, FL.
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Montgomery KB, Sarosi GA, Spain DA, Lindeman B. Precision Medicine as a Blueprint for Surgical Education: Concepts and Competencies. Ann Surg 2023; 277:e981-e983. [PMID: 36521098 PMCID: PMC10264541 DOI: 10.1097/sla.0000000000005777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - George A. Sarosi
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - David A. Spain
- Department of Surgery, Stanford University, Palo Alto, CA, USA
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Nyren MQ, Filiberto AC, Underwood PW, Abbott KL, Balch JA, Efron PA, George BC, Shickel B, Upchurch GR, Sarosi GA, Loftus TJ. A simulation curriculum for laparoscopic common bile duct exploration, balloon sphincterotomy, and endobiliary stenting: Associations with resident performance and autonomy in the operating room. Surgery 2023; 173:950-956. [PMID: 36517292 DOI: 10.1016/j.surg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration is safe and effective for managing choledocholithiasis, but laparoscopic common bile duct exploration is rarely performed, which threatens surgical trainee proficiency. This study tests the hypothesis that prior operative or simulation experience with laparoscopic common bile duct exploration is associated with greater resident operative performance and autonomy without adversely affecting patient outcomes. METHODS This longitudinal cohort study included 33 consecutive patients undergoing laparoscopic common bile duct exploration in cases involving postgraduate years 3, 4, and 5 general surgery residents at a single institution during the implementation of a laparoscopic common bile duct exploration simulation curriculum. For each of the 33 cases, resident performance and autonomy were rated by residents and attendings, the resident's prior operative and simulation experience were recorded, and patient outcomes were ascertained from electronic health records for comparison among 3 cohorts: prior operative experience, prior simulation experience, and no prior experience. RESULTS Operative approach was similar among cohorts. Overall morbidity was 6.1% and similar across cohorts. The operative performance scores were higher in prior experience cohorts according to both residents (3.0 [2.8-3.0] vs 2.0 [2.0-3.0]; P = .01) and attendings (3.0 [3.0-4.0]; P < .001). The autonomy scores were higher in prior experience cohorts according to both residents (2.0 [2.0-3.0] vs 2.0 [2.0-2.0]; P = .005) and attendings (2.5 [2.0-3.0] vs 2.0 [1.0-2.0]; P = .001). Prior simulation and prior operative experience had similar associations with performance and autonomy. CONCLUSION Simulation experience with laparoscopic common bile duct exploration was associated with greater resident operative performance and autonomy, with effects that mimic prior operative experience. This illustrates the potential for simulation-based training to improve resident operative performance and autonomy for laparoscopic common bile duct exploration.
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Affiliation(s)
- Molly Q Nyren
- College of Medicine, University of Florida, Gainesville, FL
| | | | | | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | | | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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9
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Kougias P, Mi Z, Zhan M, Carson JL, Dosluoglu H, Nelson P, Sarosi GA, Arya S, Norman LE, Sharath S, Scrymgeour A, Ollison J, Calais LA, Biswas K. Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial. Contemp Clin Trials 2023; 126:107095. [PMID: 36690072 DOI: 10.1016/j.cct.2023.107095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events. METHODS A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year. RESULTS The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups. CONCLUSIONS The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms. TRIAL REGISTRATION http://clinicaltrials.gov identifier: NCT03229941.
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Affiliation(s)
- Panos Kougias
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America.
| | - Zhibao Mi
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Min Zhan
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Jeffrey L Carson
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Hasan Dosluoglu
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo/VA Western NY Healthcare System, Buffalo, NY, United States of America
| | - Peter Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, United States of America
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, General Surgery Section, Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Vascular Section, Surgery Service Line, Palo Alto Veterans Affairs Medical Center, Palo Alto, CA, United States of America
| | - L Erin Norman
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Sherene Sharath
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America
| | - Alexandra Scrymgeour
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, United States of America
| | - Jade Ollison
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America
| | - Lawrence A Calais
- Cooperative Studies Program Site Monitoring, Auditing, and Resource Team (SMART), Albuquerque, NM, United States of America
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
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Filiberto AC, Abbott KL, Shickel B, George BC, Cochran AL, Sarosi GA, Upchurch GR, Loftus TJ. Resident Operative Autonomy and Attending Verbal Feedback Differ by Resident and Attending Gender. Ann Surg Open 2023; 4:e256. [PMID: 37600892 PMCID: PMC10431433 DOI: 10.1097/as9.0000000000000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/02/2023] [Indexed: 02/05/2023] Open
Abstract
Objectives This study tests the null hypotheses that overall sentiment and gendered words in verbal feedback and resident operative autonomy relative to performance are similar for female and male residents. Background Female and male surgical residents may experience training differently, affecting the quality of learning and graduated autonomy. Methods A longitudinal, observational study using a Society for Improving Medical Professional Learning collaborative dataset describing resident and attending evaluations of resident operative performance and autonomy and recordings of verbal feedback from attendings from surgical procedures performed at 54 US general surgery residency training programs from 2016 to 2021. Overall sentiment, adjectives, and gendered words in verbal feedback were quantified by natural language processing. Resident operative autonomy and performance, as evaluated by attendings, were reported on 5-point ordinal scales. Performance-adjusted autonomy was calculated as autonomy minus performance. Results The final dataset included objective assessments and dictated feedback for 2683 surgical procedures. Sentiment scores were higher for female residents (95 [interquartile range (IQR), 4-100] vs 86 [IQR 2-100]; P < 0.001). Gendered words were present in a greater proportion of dictations for female residents (29% vs 25%; P = 0.04) due to male attendings disproportionately using male-associated words in feedback for female residents (28% vs 23%; P = 0.01). Overall, attendings reported that male residents received greater performance-adjusted autonomy compared with female residents (P < 0.001). Conclusions Sentiment and gendered words in verbal feedback and performance-adjusted operative autonomy differed for female and male general surgery residents. These findings suggest a need to ensure that trainees are given appropriate and equitable operative autonomy and feedback.
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Affiliation(s)
- Amanda C. Filiberto
- From the Department of Surgery, University of Florida Health, Gainesville, FL
| | - Kenneth L. Abbott
- From the Department of Surgery, University of Florida Health, Gainesville, FL
| | - Benjamin Shickel
- Department of Medicine, University of Florida Health, Gainesville, FL
| | - Brian C. George
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | - Amalia L. Cochran
- From the Department of Surgery, University of Florida Health, Gainesville, FL
| | - George A. Sarosi
- From the Department of Surgery, University of Florida Health, Gainesville, FL
| | - Gilbert R. Upchurch
- From the Department of Surgery, University of Florida Health, Gainesville, FL
| | - Tyler J. Loftus
- From the Department of Surgery, University of Florida Health, Gainesville, FL
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11
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Nyren MQ, Filiberto AC, Underwood PW, Abbott KL, Balch JA, Mas FD, Cobianchi L, Efron PA, George BC, Shickel B, Upchurch GR, Sarosi GA, Loftus TJ. Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback. World J Emerg Surg 2023; 18:13. [PMID: 36747289 PMCID: PMC9901129 DOI: 10.1186/s13017-023-00480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. METHODS Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). RESULTS Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p < .001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p = .009) and attendings (69% vs. 32%, p < .01). CONCLUSIONS Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations.
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Affiliation(s)
- Molly Q. Nyren
- grid.15276.370000 0004 1936 8091University of Florida College of Medicine, Gainesville, FL USA
| | - Amanda C. Filiberto
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Patrick W. Underwood
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Kenneth L. Abbott
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Jeremy A. Balch
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Francesca Dal Mas
- grid.7240.10000 0004 1763 0578Department of Management, Ca’ Foscari University of Venice, Venice, Italy
| | - Lorenzo Cobianchi
- grid.8982.b0000 0004 1762 5736Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy ,grid.419425.f0000 0004 1760 3027IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Philip A. Efron
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Brian C. George
- grid.214458.e0000000086837370Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Benjamin Shickel
- grid.15276.370000 0004 1936 8091Department of Biomedical Engineering, University of Florida, Gainesville, FL USA
| | - Gilbert R. Upchurch
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - George A. Sarosi
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Tyler J. Loftus
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
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12
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Kang H, Ben-David K, Sarosi GA, Thomas RM. Routine Radiologic Assessment for Anastomotic Leak Is Not Necessary in Asymptomatic Patients After Esophagectomy for Esophageal Cancer. J Gastrointest Surg 2022; 26:279-285. [PMID: 35037179 DOI: 10.1007/s11605-021-05219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy. METHODS A retrospective database of esophageal cancer patients who underwent esophagectomy at a single institution from 2004 to 2020 was used to determine the utilization, timing, and sensitivity of radiologic testing for AL post-esophagectomy. RESULTS Seventy-six patients were identified of which 37 (49%) had a cervical anastomosis. Sixty-four (84%) underwent 71 "asymptomatic radiographic leak tests" (ARLT), 7 of which had 2 different tests, including: 41 fluoroscopic esophagrams (58%), 18 CT-esophagrams (25%), and 12 upper GI studies (17%). Seventeen patients (22%) developed clinical signs of AL (hemodynamic instability, leukocytosis) and underwent "symptomatic radiographic leak tests" (SRLT) with fluoroscopic esophagram (n = 9, 12%), CT-esophagram (n = 7, 9%), or upper GI study (n = 1, 1%). ARLT and SRLT were positive in 2/64 (3%) and 17/17 (100%) patients, respectively, for 19 total ALs (25%). Among the 17 SRLT( +) patients, 1 was also ARLT( +), 13 were initially ARLT( -), and 3 were not evaluated by ARLT. The median postoperative day for ARLT and SRLT was 4.0 (IQR 3.0-5.5) and 9.0 days (IQR 6.0-13.0), respectively, with a statistically significant difference (p < 0.005). The sensitivity and specificity of ARLT for detecting AL were 13.3% and 100.0%, respectively. CONCLUSIONS Based on the low ARLT sensitivity, routine use of imaging to detect asymptomatic ALs post-esophagectomy may be limited. Symptomatic ALs were often present in a delayed fashion, even after initial negative imaging.
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Affiliation(s)
- Hansol Kang
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Kfir Ben-David
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - George A Sarosi
- Section of General Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA
| | - Ryan M Thomas
- Section of General Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA. .,Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA.
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13
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Balch JA, Cooper LA, Filiberto AC, Chan PE, Riner AN, Sarosi GA, Tan SA. Corrigendum to Prevalence and extent of industry support for program directors of surgical fellowships in the United States [Surgery Volume 168, Issue 6, December 2020, Pages 1101-1105]. Surgery 2021; 169:1564. [PMID: 33789814 DOI: 10.1016/j.surg.2021.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeremy A Balch
- University of Florida Department of Surgery, Gainesville, FL
| | - Lou Ann Cooper
- University of Florida Department of Surgery, Gainesville, FL
| | | | - Patricia E Chan
- University of Florida Department of Surgery, Gainesville, FL
| | - Andrea N Riner
- University of Florida Department of Surgery, Gainesville, FL
| | - George A Sarosi
- University of Florida Department of Surgery, Gainesville, FL
| | - Sanda A Tan
- University of Florida Department of Surgery, Gainesville, FL
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14
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Loftus TJ, Filiberto AC, Upchurch GR, Hall DJ, Mira JC, Taylor J, Shaw CM, Tan SA, Sarosi GA. Performance Improvement With Implementation of a Surgical Skills Curriculum. J Surg Educ 2021; 78:561-569. [PMID: 32888847 PMCID: PMC7462643 DOI: 10.1016/j.jsurg.2020.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/23/2020] [Accepted: 08/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To assess the efficacy of an intern surgical skills curriculum involving a boot camp for core open and laparoscopic skills, self-guided practice with positive and negative incentives, and semiannual performance evaluations. DESIGN Longitudinal cohort study. SETTING Academic tertiary care center. PARTICIPANTS Intervention group (n = 15): residents who completed the intern surgical skills curriculum and had performance evaluations in fall of intern year, spring of intern year, and fall of second year. Control group (n = 8): second-year residents who were 1 year ahead of the intervention group in the same residency program, did not participate in the curriculum, and had performance evaluations in fall of second year. RESULTS In fall of second year of residency, the intervention group had better performance (presented as median values with interquartile ranges) than the control group on one-hand ties (left hand: 9.1 [6.3-10.1] vs 14.6 [13.5-15.4] seconds, p = 0.007; right hand: 8.7 [8.5-9.6] vs 11.5 [9.9-16.8] seconds, p = 0.039). The intervention group also had better performance on all open suturing skills, including mattress suturing (vertical: 33.4 [30.0-40.0] vs 55.8 [50.0-67.6] seconds, p = 0.001; horizontal: 28.7 [27.3-39.9] vs 52.7 [40.7-57.8] seconds, p = 0.003), and a water-filled glove clamp, divide, and ligate task (28.0 [25.0-31.0] vs 59.1 [53.0-93.0] seconds, p < 0.001). Finally, the intervention group had better performance on all laparoscopic skills, including peg transfer (66.0 [59.0-82.0] vs 95.2 [87.5-101.5] seconds, p = 0.018), circle cut (82.0 [69.0-124.0] seconds vs 191.8 [155.5-231.5] seconds, p = 0.002), and intracorporeal suturing (195.0 [117.0-200.0] seconds vs 359.5 [269.0-450.0] seconds, p = 0.002). CONCLUSIONS Implementation of a comprehensive surgical skills curriculum was associated with improved performance on core open and laparoscopic skills. Further research is needed to understand and optimize motivational factors for deliberate practice and surgical skill acquisition.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Amanda C Filiberto
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - David J Hall
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Juan C Mira
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Janice Taylor
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Christiana M Shaw
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Sanda A Tan
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, Florida.
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15
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Filiberto AC, Cooper LA, Loftus TJ, Samant SS, Sarosi GA, Tan SA. Objective predictors of intern performance. BMC Med Educ 2021; 21:77. [PMID: 33499857 PMCID: PMC7839184 DOI: 10.1186/s12909-021-02487-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/14/2020] [Indexed: 05/15/2023]
Abstract
BACKGROUND Residency programs select medical students for interviews and employment using metrics such as the United States Medical Licensing Examination (USMLE) scores, grade-point average (GPA), and class rank/quartile. It is unclear whether these metrics predict performance as an intern. This study tested the hypothesis that performance on these metrics would predict intern performance. METHODS This single institution, retrospective cohort analysis included 244 graduates from four classes (2015-2018) who completed an Accreditation Council for Graduate Medical Education (ACGME) certified internship and were evaluated by program directors (PDs) at the end of the year. PDs provided a global assessment rating and ratings addressing ACGME competencies (response rate = 47%) with five response options: excellent = 5, very good = 4, acceptable = 3, marginal = 2, unacceptable = 1. PDs also classified interns as outstanding = 4, above average = 3, average = 2, and below average = 1 relative to other interns from the same residency program. Mean USMLE scores (Step 1 and Step 2CK), third-year GPA, class rank, and core competency ratings were compared using Welch's ANOVA and follow-up pairwise t-tests. RESULTS Better performance on PD evaluations at the end of intern year was associated with higher USMLE Step 1 (p = 0.006), Step 2CK (p = 0.030), medical school GPA (p = 0.020) and class rank (p = 0.016). Interns rated as average had lower USMLE scores, GPA, and class rank than those rated as above average or outstanding; there were no significant differences between above average and outstanding interns. Higher rating in each of the ACGME core competencies was associated with better intern performance (p < 0.01). CONCLUSIONS Better performance as an intern was associated with higher USMLE scores, medical school GPA and class rank. When USMLE Step 1 reporting changes from numeric scores to pass/fail, residency programs can use other metrics to select medical students for interviews and employment.
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Affiliation(s)
- Amanda C Filiberto
- Department of Surgery, University of Florida Health, 1600 SW Archer Ave, PO Box 100109, Gainesville, FL, 32610, USA
| | - Lou Ann Cooper
- Office for Educational Affairs, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, 1600 SW Archer Ave, PO Box 100109, Gainesville, FL, 32610, USA
| | - Sonja S Samant
- University of Florida College of Medicine, Gainesville, FL, USA
| | - George A Sarosi
- Department of Surgery, University of Florida Health, 1600 SW Archer Ave, PO Box 100109, Gainesville, FL, 32610, USA
| | - Sanda A Tan
- Department of Surgery, University of Florida Health, 1600 SW Archer Ave, PO Box 100109, Gainesville, FL, 32610, USA.
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16
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Balch JA, Cooper LA, Filiberto AC, Chan PE, Sarosi GA, Tan SA. Prevalence and extent of industry support for program directors of surgical fellowships in the United States. Surgery 2020; 168:1101-1105. [PMID: 32943202 DOI: 10.1016/j.surg.2020.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fellowship program directors have a considerable influence on the future practice patterns of their trainees. Multiple studies have demonstrated that industry can also exert substantial influence on the practice patterns of physicians as a whole. The purpose of this study is to quantify industry support of fellowship program directors across surgical subspecialties and to assess the prevalence of this support within specific subspecialties. METHODS Fellowship program directors for acute care, breast, burn, cardio-thoracic, critical care, colon and rectal, endocrine, hepato-pancreato-biliary, minimally invasive, plastic, oncologic, pediatric, and vascular surgery for 2017 were identified using a previously described database. The Open Payments Database for 2017 was queried and data regarding general payments, research, associated research payments, and ownership were obtained. The national mean and median payouts to nonfellowship program director surgeons were used to determine subspecialties with substantial industry support. RESULTS Five hundred and seventy-six fellowship program directors were identified. Of these, 77% of the fellowship program directors had a presence on the Open Payments Database. The subspecialties with the most fellowship program directors receiving any industry payment, regardless of amount, included vascular (93.5%), cardio-thoracic (92.8%), minimally invasive surgery (90.5%), plastics (85.3%), and colon and rectal (81.0%). The subspecialty with the greatest mean payment was minimally invasive surgery (21,175 US dollars); the greatest median payment was vascular (1,871 US dollars). The 3 most common types of payments were for general compensation (31.4%), consulting fees (28.7%), and travel and lodging (14.7%). Vascular surgery had the greatest percentage of fellowship program directors receiving research payments (48%). The greatest amount paid to any individual fellowship program director was 382,368 US dollars. Excluding outliers, fellowship program directors received substantially more payments than those received on average by general surgeons. CONCLUSION The majority of fellowship program directors receive some industry support. Most payments are for compensation for noncontinuing medical education related services and consulting fees. Certain specialties were more likely to have industry payments than others. Overall, only a minority of fellowship program directors received research support from industry. We advocate for transparent discussions between fellowship program directors and their trainees to help foster healthy academic-industry collaborations.
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Affiliation(s)
- Jeremy A Balch
- University of Florida Department of Surgery, Gainesville, FL
| | - Lou Ann Cooper
- University of Florida Department of Surgery, Gainesville, FL
| | | | - Patricia E Chan
- University of Florida Department of Surgery, Gainesville, FL
| | - George A Sarosi
- University of Florida Department of Surgery, Gainesville, FL
| | - Sanda A Tan
- University of Florida Department of Surgery, Gainesville, FL.
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17
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Oppenheimer EE, Schmit B, Sarosi GA, Thomas RM. Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery. J Surg Res 2020; 256:570-576. [PMID: 32805579 DOI: 10.1016/j.jss.2020.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/22/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life. METHODS A retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use. RESULTS Sixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD. CONCLUSIONS Most patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.
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Affiliation(s)
- Eittel E Oppenheimer
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Bradley Schmit
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida; Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ryan M Thomas
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida; Department of Surgery, University of Florida College of Medicine, Gainesville, Florida.
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18
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Jarman BT, Borgert AJ, Kallies KJ, Joshi ART, Smink DS, Sarosi GA, Chang L, Green JM, Greenberg JA, Melcher ML, Nfonsam V, Whiting J. Underrepresented Minorities in General Surgery Residency: Analysis of Interviewed Applicants, Residents, and Core Teaching Faculty. J Am Coll Surg 2020; 231:54-58. [PMID: 32156654 DOI: 10.1016/j.jamcollsurg.2020.02.042] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/10/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) requires diversity in residency. The self-identified race/ethnicities of general surgery applicants, residents, and core teaching faculty were assessed to evaluate underrepresented minority (URM) representation in surgery residency programs and to determine the impact of URM faculty and residents on URM applicants' selection for interview or match. STUDY DESIGN Data from the 2018 application cycle were collated for 10 general surgery programs. Applicants without a self-identified race/ethnicity were excluded. URMs were defined as those identifying as black/African American, Hispanic/Latino/of Spanish origin, and American Indian/Alaskan Native/Native Hawaiian/Pacific Islander-Samoan. Statistical analyses included chi-square tests and a multivariate model. RESULTS Ten surgery residency programs received 9,143 applications from 3,067 unique applicants. Applications from white, Asian, Hispanic/Latino, black/African American, and American Indian applicants constituted 66%, 19%, 8%, 7% and 1%, respectively, of those applications selected to interview and 66%, 13%, 11%, 8%, and 2%, respectively, of applications resulting in a match. Among programs' 272 core faculty and 318 current residents, 10% and 21%, respectively, were identified as URMs. As faculty diversity increased, there was no difference in selection to interview for URM (odds ratio [OR] 0.83; 95% CI 0.54 to 1.28, per 10% increase in faculty diversity) or non-URM applicants (OR 0.68; 95% CI 0.57 to 0.81). Similarly, greater URM representation among current residents did not affect the likelihood of being selected for an interview for URM (OR 1.20; 95%CI 0.90 to 1.61) vs non-URM applicants (OR 1.28; 95% CI 1.13 to 1.45). Current resident and faculty URM representation was correlated (r = 0.8; p = 0.005). CONCLUSIONS Programs with a greater proportion of URM core faculty or residents did not select a greater proportion of URM applicants for interview. However, core faculty and resident racial diversity were correlated. Recruitment of racially/ethnically diverse trainees and faculty will require ongoing analysis to develop effective recruitment strategies.
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Affiliation(s)
- Benjamin T Jarman
- Department of General Surgery, Gundersen Health System, La Crosse, WI.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, WI
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI
| | - Amit R T Joshi
- Department of Surgery, Einstein Healthcare Network, Philadelphia, PA
| | - Douglas S Smink
- Department of Surgery, Brigham & Women's Hospital, Boston, MA
| | - George A Sarosi
- Department of Surgery, University of Florida, Gainesville, FL
| | - Lily Chang
- Department of General Surgery, Virginia Mason Medical Center, Seattle, WA
| | - John M Green
- Department of General Surgery, Carolinas HealthCare System, Charlotte, NC
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Marc L Melcher
- Department of Surgery, Stanford University, Stanford, CA
| | | | - James Whiting
- Department of Surgery, Maine Medical Center, Portland, ME
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19
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Loftus TJ, Hall DJ, Malaty JZ, Kuruppacherry SB, Sarosi GA, Shaw CM, Tan SA, Taylor J, Morris DS, Meyer LE, Hobbs JA. Associations Between National Board Exam Performance and Residency Program Emphasis on Patient Safety and Interprofessional Teamwork. Acad Psychiatry 2019; 43:581-584. [PMID: 31456123 DOI: 10.1007/s40596-019-01106-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Several aspects of medical training may contribute to the ultimate goal of producing excellent physicians whose patients will have the best possible outcomes. However, the relative importance of education, evaluation and feedback, duty hours, practice structure, and program culture in achieving this goal is unclear. This study assessed associations among in-training exam performance, Accreditation Council for Graduate Medical Education (ACGME) Resident Survey responses, and American Board of Medical Specialties (ABMS) national board exam performance. METHODS Residency training programs at a university teaching hospital were classified as having 5-year first-time ABMS pass rates above (n=12) or below (n=3) the national average for their specialty. These groups were compared by ACGME Resident Survey data and in-training exam performance. RESULTS Surveys were collected from 484/543 eligible residents (89%), including 177 surveys from programs with below-average board pass rates and 307 surveys from programs with aboveaverage board pass rates. In-training exam performance was similar between groups. Aboveaverage programs had stronger agreement with statements that their culture reinforced patient safety (4.72 vs. 4.30, p=0.006) and that information was not lost during transitions of care (4.14 vs. 3.63, p=0.001). Although the occurrence of interprofessional teamwork was similar between groups, above-average programs had stronger agreement with the statement that interprofessional teamwork was effective (4.60 vs. 4.17, p=0.003). CONCLUSION Residency programs emphasizing patient safety and effective interprofessional teamwork had above-average first-time national board pass rates.
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Affiliation(s)
| | - David J Hall
- University of Florida Health, Gainesville, FL, USA
| | | | | | | | | | - Sanda A Tan
- University of Florida Health, Gainesville, FL, USA
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Jarman BT, Kallies KJ, Joshi ART, Smink DS, Sarosi GA, Chang L, Green JM, Greenberg JA, Melcher ML, Nfonsam V, Ramirez LD, Borgert AJ, Whiting J. Underrepresented Minorities are Underrepresented Among General Surgery Applicants Selected to Interview. J Surg Educ 2019; 76:e15-e23. [PMID: 31175064 DOI: 10.1016/j.jsurg.2019.05.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Diversity is an ill-defined entity in general surgery training. The Accreditation Council for Graduate Medical Education recently proposed new common program requirements including verbiage requiring diversity in residency. "Recruiting" for diversity can be challenging within the constraints of geographic preference, type of program, and applicant qualifications. In addition, the Match process adds further uncertainty. We sought to study the self-identified racial/ethnic distribution of general surgery applicants to better ascertain the characteristics of underrepresented minorities (URM) within the general surgery applicant pool. DESIGN Program-specific data from the Electronic Residency Application Service was collated for the 2018 medical student application cycle. Data were abstracted for all participating programs' applicants and those selected to interview. Applicants who did not enter a self-identified race/ethnicity were excluded from analysis. URM were defined as those identifying as Black/African American, Hispanic/Latino/of Spanish origin, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander-Samoan. Appropriate statistical analyses were accomplished. SETTING Ten general surgery residency programs-5 independent programs and 5 university programs. PARTICIPANTS Residency applicants to the participating general surgery residency programs. RESULTS Ten surgery residency programs received 10,312 applications from 3192 unique applicants. Seven hundred and seventy-eight applications did not include a self-identified race/ethnicity and were excluded from analysis. The racial/ethnic makeup of applicants in this study cohort was similar to that from 2017 to 2018 Electronic Residency Application Service data of 4262 total applicants to categorical general surgery. Programs received a median of 1085 (range: 485-1264) applications each and altogether selected 617 unique applicants for interviews. Overall, 2148 applicants graduated from US medical schools, and of those, 595 (28%) were offered interviews. The mean age of applicants was 28.8 ± 3.8 years and 1316 (41%) were female. Hispanic/Latino/of Spanish origin, Black, and American Indian/Alaskan Native/Hawaiian/Pacific Islander-Samoan applicants constituted 12%, 8%, and 1% of total applicants, but only 8%, 6%, and 1% of those selected for interview. Overall, 29% of applicants had United States Medical Licensing Examination (USMLE) Step 1 scores ≤220; 37 (6%) of those selected for interviews had a USMLE Step 1 score of ≤220. A higher proportion of URM applicants had USMLE scores ≤220 compared to White and Asian applicants. Non-white self-identification was a significant independent predictor of a lower likelihood of interview selection. Female gender, USMLE Step 1 score >220, and graduating from a US medical school were associated with an increased likelihood of being selected to interview. CONCLUSIONS URM applicants represented a disproportionately smaller percentage of applicants selected for interview. USMLE Step 1 scores were lower among the URM applicants. Training programs that use discreet USMLE cutoffs are likely excluding URM at a higher rate than their non-URM applicants. Attempts to recruit racially/ethnically diverse trainees should include program-level analysis to determine disparities and a focused strategy to interview applicants who might be overlooked by conventional screening tools.
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Affiliation(s)
- Benjamin T Jarman
- Gundersen Health System and Gundersen Medical Foundation, La Crosse, Wisconsin.
| | - Kara J Kallies
- Gundersen Health System and Gundersen Medical Foundation, La Crosse, Wisconsin
| | | | | | | | - Lily Chang
- Virginia Mason Medical Center, Seattle, Washington
| | - John M Green
- Carolinas Medical Center, Charlotte, North Carolina
| | | | | | | | - Luis D Ramirez
- Gundersen Health System and Gundersen Medical Foundation, La Crosse, Wisconsin
| | - Andrew J Borgert
- Gundersen Health System and Gundersen Medical Foundation, La Crosse, Wisconsin
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21
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Filiberto AC, Le CB, Loftus TJ, Cooper LA, Shaw C, Sarosi GA, Iqbal A, Tan SA. Gender differences among surgical fellowship program directors. Surgery 2019; 166:735-737. [PMID: 31256855 DOI: 10.1016/j.surg.2019.05.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/04/2019] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although women are increasingly represented in American surgery, data regarding sex and academic rank of the leadership of fellowship programs are lacking. METHODS Demographics and academic ranks for fellowship program directors were analyzed for 811 surgery fellowship programs across 14 specialties. Associations between academic rank and sex were assessed using a χ2 independence test. Correlation between subspecialty compensation and percentage of female fellowship program directors was assessed using Pearson r. RESULTS Women represented 18% of all fellowship program directors. Eighteen percent of fellowship program directors were assistant professors (25% women vs 17% men, P = .049), 36% were associate professors (39% women vs 35% men, P = .379), and 46% were full professors (36% women vs 48% men, P = .018). The percentage of women program directors was greatest in breast surgery (65%) and least in minimally invasive surgery (6%). There was a negative correlation between subspecialty compensation and percentage of female fellowship program directors (r = -0.62, P = .04). CONCLUSION Women are underrepresented among surgery fellowship program directors. Female fellowship program directors had lesser academic ranks compared with males. It remains unclear whether women surgeons achieve program director appointments at lesser academic ranks or if promotion among fellowship program directors is influenced by sex.
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Affiliation(s)
| | | | - Tyler J Loftus
- University of Florida Department of Surgery, Gainesville, FL
| | - Lou A Cooper
- University of Florida Department of Surgery, Gainesville, FL
| | - Christiana Shaw
- University of Florida Department of Surgery, Gainesville, FL
| | - George A Sarosi
- University of Florida Department of Surgery, Gainesville, FL
| | - Atif Iqbal
- University of Florida Department of Surgery, Gainesville, FL
| | - Sanda A Tan
- University of Florida Department of Surgery, Gainesville, FL.
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Carpenter AM, Tan SA, Costopoulos K, Cooper LA, Sarosi GA, Shaw CM. Gender Diversity in General Surgery Residency Leadership. J Surg Educ 2018; 75:e68-e71. [PMID: 30177356 DOI: 10.1016/j.jsurg.2018.07.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/17/2018] [Accepted: 07/30/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE This study aimed to evaluate the proportion and characteristics of women who serve in general surgery program director (PD) and associate program director (APD) positions in the United States. DESIGN General surgery programs (n = 276) and directors were identified using the Association for Program Directors in Surgery website; information was cross-referenced with American Medical Association FREIDA and Accreditation Council for Graduate Medical Education databases, current to July 1, 2017. Each program's website was accessed to determine the gender and academic ranking of faculty. RESULTS Results reveal a preponderance of men in PD and APD positions. Women accounted for 18.4% (n = 51) of the 276 PD positions, with more women in APD positions (29.6%). There was no correlation between gender of PD and the corresponding APD, (χ2 = 0.68, p = 0.41; Phi coefficient = -0.0695). Of those with academic appointments, men who were PDs were more likely to be full professors when compared to women PDs (38.5% vs 24.1%, respectively). The median number of days since appointment to PD was similar in both groups (1461 days for men vs 1377 for women, p = 0.18), although more men have held PD positions longer. Programs with a higher proportion of women faculty were more likely to have a woman PD (p = 0.0397), but not those with more women residents (p = 0.225) or a woman Department Chair (p = 0.56). CONCLUSIONS Among general surgery program directorship, men continue to hold more positions of educational leadership, although the trend appears to be shifting toward a more equal balance, particularly in those programs with proportionately more women faculty. This discrepancy may be due to academic rank or length of tenure. As more women hold academic positions in the field of general surgery, an increase in the representation of this group in leadership is anticipated. Although senior leadership (PD) positions remain disproportionately held by men, APD positions are filled by a greater percentage of women than academic surgical faculty, although the absolute percentage remains less than 50%. Educational leadership may be a viable path to academic leadership for both women and men.
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Affiliation(s)
| | - Sanda A Tan
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | | | - Lou Ann Cooper
- University of Florida, College of Medicine, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida.
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Loftus TJ, Lopez AN, Jenkins TK, Downey EM, Sikora JR, Pelletier JPR, Zendejas IR, Sarosi GA, Thomas RM. Packed red blood cell donor age affects overall survival in transfused patients undergoing hepatectomy for non-hepatocellular malignancy. Am J Surg 2018; 217:71-77. [PMID: 30172359 DOI: 10.1016/j.amjsurg.2018.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/19/2018] [Accepted: 08/23/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients undergoing hepatectomy often require packed red blood cell (PRBC) transfusion, which has been associated with worse oncologic outcomes. However, limited data exist regarding the impact of PRBC donor factors. We hypothesized that PRBC donor age impacts survival after hepatectomy for non-hepatocellular malignancies. METHODS Patients who underwent hepatectomy for non-hepatocellular malignancy from 2005 to 2014 were retrospectively evaluated. Impact of clinicopathologic and PRBC factors on oncologic outcomes were assessed. RESULTS Of 149 identified patients, 76 received a perioperative PRBC transfusion (median 2 units). Transfusion was associated with increased median length of stay (8 vs. 6 days; p < 0.01) and median operative blood loss (700 vs. 350 mL; p < 0.01) versus non-transfused, respectively. In transfused patients, receipt of PRBC from older donors compared to younger resulted in decreased RFS (0.94 vs. 2.63 years, respectively; p = 0.02) and OS (1.94 vs. 3.44 years, respectively; p = 0.6). The PRBC donor age was an independent predictor of decreased recurrence free survival on multivariate analysis (HR 2.5, p = 0.04). CONCLUSIONS In patients undergoing hepatectomy for non-hepatocellular malignancies and receiving perioperative transfusion, PRBC donor age may impact survival and warrants further investigation.
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Affiliation(s)
- Tyler J Loftus
- University of Florida College of Medicine, Department of Surgery, Gainesville, FL, USA
| | | | | | | | - James R Sikora
- University of Florida, Department of Pathology, Immunology, and Laboratory Medicine, Gainesville, FL, USA
| | - J Peter R Pelletier
- University of Florida, Department of Pathology, Immunology, and Laboratory Medicine, Gainesville, FL, USA
| | | | - George A Sarosi
- University of Florida College of Medicine, Department of Surgery, Gainesville, FL, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, Gainesville, FL, USA
| | - Ryan M Thomas
- University of Florida College of Medicine, Department of Surgery, Gainesville, FL, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, Gainesville, FL, USA.
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24
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Affiliation(s)
- Christiana Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - George A. Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville
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25
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Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, Brown KK, Mehta A, Husta B, Ryu JH, Sarosi GA, Franquet T, Verschakelen J, Johkoh T, Travis W, Raoof S. Cavitary Lung Diseases. Chest 2018. [DOI: 10.1016/j.chest.2018.02.026] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Olsen KR, Hall DJ, Mira JC, Underwood PW, Antony AB, Vasilopoulos T, Sarosi GA. Postoperative surgical trainee opioid prescribing practices (POST OPP): an institutional study. J Surg Res 2018; 229:58-65. [PMID: 29937017 DOI: 10.1016/j.jss.2018.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/02/2018] [Accepted: 03/13/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Increasing mortality from opioid overdoses has prompted increased focus on prescribing practices of physicians. Unfortunately, resident physicians rarely receive formal education in effective opioid prescribing practices or postoperative pain management. Data to inform surgical training programs regarding the utility and feasibility of formal training are lacking. METHODS Following Institutional Review Board approval, a single institution's resident physicians who had completed at least one surgical rotation were surveyed to assess knowledge of pain management and evaluate opioid prescribing practices. RESULTS Fifty-three respondents (68% males and 32% females) completed the survey. Most respondents denied receiving formal instruction in opioid pain medication prescribing practices during either medical school (62.3%) or residency (56.6%); however, nearly all respondents stated they were aware of the side effects of opioid pain medications, and a majority felt confident in their knowledge of opioid pharmacokinetics and pharmacodynamics. Of the respondents, 47% either "agreed" or "strongly agreed" that they prescribed more opioid medications than necessary to patients being discharged following a surgical procedure. Individual case scenario responses demonstrated variability in the number of morphine milligram equivalents prescribed across scenarios (P < 0.001). Male and nonsurgical specialty respondents reported prescribing significantly fewer overall morphine milligram equivalents in these scenarios. CONCLUSIONS This pilot study shows wide variability in opioid prescribing practices and attitudes toward pain management among surgical trainees, illustrating the potential utility of formal education in pain management and effective prescribing of these medications. A broader assessment of surgical trainees' knowledge and perception of opioid prescribing practices is warranted to facilitate the development of such a program.
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Affiliation(s)
- Kevin R Olsen
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.
| | - David J Hall
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Juan C Mira
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Patrick W Underwood
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ajay B Antony
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida; Department of Orthopedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
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27
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Jenkins TK, Lopez AN, Sarosi GA, Ben-David K, Thomas RM. Preoperative enteral access is not necessary prior to multimodality treatment of esophageal cancer. Surgery 2018; 163:770-776. [DOI: 10.1016/j.surg.2017.09.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 09/06/2017] [Accepted: 09/27/2017] [Indexed: 01/21/2023]
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Meyers MO, Sarosi GA, Brasel KJ. Perspective of Residency Program Directors on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours. JAMA Surg 2017; 152:905-906. [DOI: 10.1001/jamasurg.2017.2206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - George A. Sarosi
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville3University of Florida, Gainesville
| | - Karen J. Brasel
- Department of Surgery, Oregon Health and Science University, Portland
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29
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Loftus TJ, Brakenridge SC, Dessaigne CG, Sarosi GA, Zingarelli WJ, Moore FA, Jordan JR, Croft CA, Smith RS, Efron PA, Mohr AM. Antibiotics May be Safely Discontinued Within One Week of Percutaneous Cholecystostomy. World J Surg 2017; 41:1239-1245. [PMID: 28050668 DOI: 10.1007/s00268-016-3861-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND For patients with acute cholecystitis managed with percutaneous cholecystostomy (PC), the optimal duration of post-procedural antibiotic therapy is unknown. Our objective was to compare short versus long courses of antibiotics with the hypothesis that patients with persistent signs of systemic inflammation 72 h following PC would receive prolonged antibiotic therapy and that antibiotic duration would not affect outcomes. METHODS We performed a retrospective cohort analysis of 81 patients who underwent PC for acute cholecystitis at two hospitals during a 41-month period ending November 2014. Patients who received short (≤7 day) courses of post-procedural antibiotics were compared to patients who received long (>7 day) courses. Treatment response to PC was evaluated by systemic inflammatory response syndrome (SIRS) criteria. Logistic and linear regressions were used to evaluate associations between antibiotic duration and outcomes. RESULTS Patients who received short (n = 30) and long courses (n = 51) of antibiotics had similar age, comorbidities, severity of cholecystitis, pre-procedural vital signs, treatment response, and culture results. There were no differences in recurrent cholecystitis (13 vs. 12%), requirement for open/converted to open cholecystectomy (23 vs. 22%), or 1-year mortality (20 vs. 18%). On logistic and linear regressions, antibiotic duration as a continuous variable was not predictive of any salient outcomes. CONCLUSIONS Patients who received short and long courses of post-PC antibiotics had similar baseline characteristics and outcomes. Antibiotic duration did not predict recurrent cholecystitis, interval open cholecystectomy, or mortality. These findings suggest that antibiotics may be safely discontinued within one week of uncomplicated PC.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - Scott C Brakenridge
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA
| | - Camille G Dessaigne
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - George A Sarosi
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - William J Zingarelli
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA
| | - Janeen R Jordan
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - Chasen A Croft
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - R Stephen Smith
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - Phillip A Efron
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA.
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
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30
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Affiliation(s)
- Anjum S Kaka
- Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
| | - George A Sarosi
- Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
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31
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Duff JM, Peters HC, Zingarelli W, Ben-David K, Sarosi GA, Thomas RM. Comparative Effectiveness of Preoperative Treatment Regimens in Patients With Potentially Resectable Esophageal Cancer. JAMA Surg 2017; 152:103-105. [PMID: 27627680 DOI: 10.1001/jamasurg.2016.2821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jennifer M Duff
- Section of Hematology/Oncology, Department of Medicine, North Florida/South Georgia Veterans Health System and the University of Florida, Gainesville
| | - H Charles Peters
- Department of Surgery, North Florida/South Georgia Veterans Health System and the University of Florida, Gainesville
| | - William Zingarelli
- Department of Surgery, North Florida/South Georgia Veterans Health System and the University of Florida, Gainesville
| | - Kfir Ben-David
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, Florida
| | - George A Sarosi
- Department of Surgery, North Florida/South Georgia Veterans Health System and the University of Florida, Gainesville
| | - Ryan M Thomas
- Department of Surgery, North Florida/South Georgia Veterans Health System and the University of Florida, Gainesville
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32
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Delitto D, Judge SM, George TJ, Sarosi GA, Thomas RM, Behrns KE, Hughes SJ, Judge AR, Trevino JG. A clinically applicable muscular index predicts long-term survival in resectable pancreatic cancer. Surgery 2016; 161:930-938. [PMID: 27932030 DOI: 10.1016/j.surg.2016.09.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/30/2016] [Accepted: 09/07/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND The relationship between myopenia, nutritional status, and long-term oncologic outcomes remains poorly characterized in patients with clinically resectable pancreatic cancer. We sought to reliably quantify prognostic indicators of preoperative cachexia in a manner applicable to any clinical setting. METHODS Preoperative computed tomographies were available electronically and suitable for analysis in 73 of 82 consecutive patients with pancreatic cancer undergoing pancreatoduodenectomy between November 2010 and February 2014. The psoas index was computed from the cross-sectional area of the psoas muscles normalized to vertebral body area at the third lumbar vertebra. Correlation and proportional hazards analyses were performed to identify relationships between muscularity, preoperative nutritional markers, clinicopathologic parameters, and long-term survival. RESULTS The psoas index correlated strongly with preoperative hemoglobin and albumin levels (P = .001 and .014, respectively) identifying a pattern of preoperative frailty. High psoas index and the albumin and hemoglobin levels were associated with improved long-term survival (hazard ratio 0.014, P < .001; hazard ratio 0.43, P < .001; and hazard ratio = 0.80, P = .014); however, on multivariate analysis, the psoas index proved to be the only independent predictor of survival (hazard ratio 0.021; P = .003). Rapid decreases in the psoas index during neoadjuvant chemotherapy were associated with poor postoperative outcomes, as were decreases in the psoas index during the postoperative period. CONCLUSION The data indicate that the psoas index, a calculation derived from a clinically mandated, preoperative computed tomography, is a statistically powerful and easily calculated predictor of survival in pancreatic cancer when compared to tumor grade and stage as well as previously validated nutritional parameters.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Sarah M Judge
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, FL
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - George A Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Ryan M Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Kevin E Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Steven J Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Andrew R Judge
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, FL
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL.
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33
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Delitto D, Luckhurst CM, Black BS, Beck JL, George TJ, Sarosi GA, Thomas RM, Trevino JG, Behrns KE, Hughes SJ. Oncologic and Perioperative Outcomes Following Selective Application of Laparoscopic Pancreaticoduodenectomy for Periampullary Malignancies. J Gastrointest Surg 2016; 20:1343-9. [PMID: 27142633 PMCID: PMC6033586 DOI: 10.1007/s11605-016-3136-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/17/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data are sparse regarding patient selection criteria or evaluating oncologic outcomes following laparoscopic pancreaticoduodenectomy (LPD). Having prospectively limited LPD to patients with resectable disease defined by National Comprehensive Cancer Network (NCCN) criteria, we evaluated perioperative and long-term oncologic outcomes of LPD compared to a similar cohort of open pancreaticoduodenectomy (OPD). METHODS Consecutive patients (November 2010-February 2014) undergoing pancreaticoduodenectomy (PD) for periampullary adenocarcinoma were reviewed. Patients were excluded from further analysis for benign pathology, conversion to OPD for portal vein resection, and contraindications for LPD not related to their malignancy. Outcomes of patients undergoing LPD were analyzed in an intention-to-treat manner against a cohort of patients undergoing OPD. RESULTS These selection criteria resulted in offering LPD to 77 % of all cancer patients. Compared to the OPD cohort, LPD was associated with significant reductions in wound infections (16 vs. 34 %; P = 0.038), pancreatic fistula (17 vs. 36 %; P = 0.032), and median hospital stay (9 vs. 12 days; P = 0.025). Overall survival (OS) was not statistically different between patients undergoing LPD vs. OPD for periampullary adenocarcinoma (median OS 27.9 vs. 23.5 months; P = 0.955) or pancreatic adenocarcinoma (N = 28 vs. 22 patients; median OS 20.7 vs. 21.1 months; P = 0.703). CONCLUSIONS The selective application of LPD for periampullary malignancies results in a high degree of eligibility as well as significant reductions in length of stay, wound infections, and pancreatic fistula. Overall survival after LPD is similar to OPD.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Casey M. Luckhurst
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Brian S. Black
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - John L. Beck
- Department of Radiology, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Thomas J. George
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - George A. Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL,North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610
| | - Ryan M. Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL,North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610
| | - Jose G. Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Kevin E. Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Steven J. Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
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Delitto D, Black BS, Cunningham HB, Sliesoraitis S, Lu X, Liu C, Sarosi GA, Thomas RM, Trevino JG, Hughes SJ, George TJ, Behrns KE. Standardization of surgical care in a high-volume center improves survival in resected pancreatic head cancer. Am J Surg 2016; 212:195-201.e1. [PMID: 27260793 DOI: 10.1016/j.amjsurg.2016.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/27/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Durable clinical gains in surgical care are frequently reliant on well-developed standardization of practices. We hypothesized that the standardization of surgical management would result in improved long-term survival in pancreatic cancer. METHODS Seventy-seven consecutive, eligible patients representing all patients who underwent pancreaticoduodenectomy and received comprehensive, long-term postoperative care at the University of Florida were analyzed. Patients were divided into prestandardization and poststandardization groups based on the implementation of a pancreatic surgery partnership, or standardization program. RESULTS Standardization resulted in a reduction in median length of stay (10 vs 12 days; P = .032), as well as significant gains in disease-free survival (17 vs 11 months; P = .017) and overall survival (OS; 26 vs 16 months; P = .004). The improvement in overall survival remained significant on multivariate analysis (hazard ratio = .46, P = .005). CONCLUSIONS Standardization of surgical management of pancreatic cancer was associated with significant gains in long-term survival. These results suggest strongly that management of pancreatic head adenocarcinoma be standardized likely by regionalization of care at high performing oncologic surgery programs.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Brian S Black
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Holly B Cunningham
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Sarunas Sliesoraitis
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Xiaomin Lu
- Department of Biostatistics & Children's Oncology Group, College of Public Health and Health Professions, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Chen Liu
- Department of Pathology, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - George A Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Ryan M Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Steven J Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Kevin E Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA.
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Alpern JD, Bahr NC, Vazquez-Benitez G, Boulware DR, Sellman JS, Sarosi GA. Diagnostic Delay and Antibiotic Overuse in Acute Pulmonary Blastomycosis. Open Forum Infect Dis 2016; 3:ofw078. [PMID: 27419155 PMCID: PMC4943562 DOI: 10.1093/ofid/ofw078] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/13/2016] [Indexed: 11/12/2022] Open
Abstract
The diagnosis of blastomycosis is often delayed. We identified 28 cases of pulmonary blastomycosis in a retrospective chart review. Most patients received multiple antibiotic courses before being diagnosed, and the sputum KOH smear was rarely used. Diagnostic delay can be decreased with higher suspicion for pulmonary blastomycosis and early use of the sputum KOH smear.
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Affiliation(s)
- Jonathan D Alpern
- Division of Infectious Disease & International Medicine, Department of Medicine,University of Minnesota, Minneapolis; Department of Medicine, Regions Hospital, St. Paul, Minnesota
| | - Nathan C Bahr
- Division of Infectious Disease & International Medicine, Department of Medicine,University of Minnesota, Minneapolis; Division of Infectious Diseases, Department of Medicine, University of Kansas
| | | | - David R Boulware
- Division of Infectious Disease & International Medicine, Department of Medicine, University of Minnesota , Minneapolis
| | - Jonathan S Sellman
- Division of Infectious Disease, Department of Medicine , Regions Hospital , St. Paul, Minnesota
| | - George A Sarosi
- Department of Medicine, University of Minnesota, Minneapolis; Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, USA
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Delitto D, Zhang D, Han S, Black BS, Knowlton AE, Vlada AC, Sarosi GA, Behrns KE, Thomas RM, Lu X, Liu C, George TJ, Hughes SJ, Wallet SM, Trevino JG. Nicotine Reduces Survival via Augmentation of Paracrine HGF-MET Signaling in the Pancreatic Cancer Microenvironment. Clin Cancer Res 2015; 22:1787-99. [PMID: 26667487 DOI: 10.1158/1078-0432.ccr-15-1256] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 11/26/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE The relationship between smoking and pancreatic cancer biology, particularly in the context of the heterogeneous microenvironment, remains incompletely defined. We hypothesized that nicotine exposure would lead to the augmentation of paracrine growth factor signaling between tumor-associated stroma (TAS) and pancreatic cancer cells, ultimately resulting in accelerated tumor growth and metastasis. EXPERIMENTAL DESIGN The effect of tobacco use on overall survival was analyzed using a prospectively maintained database of surgically resected patients with pancreatic cancer. Nicotine exposure was evaluated in vitro using primary patient-derived TAS and pancreatic cancer cells independently and in coculture. Nicotine administration was then assessed in vivo using a patient-derived pancreatic cancer xenograft model. RESULTS Continued smoking was associated with reduced overall survival after surgical resection. In culture, nicotine-stimulated hepatocyte growth factor (HGF) secretion in primary patient-derived TAS and nicotine stimulation was required for persistent pancreatic cancer cell c-Met activation in a coculture model. c-Met activation in this manner led to the induction of inhibitor of differentiation-1 (Id1) in pancreatic cancer cells, previously established as a mediator of growth, invasion and chemoresistance. HGF-induced Id1 expression was abrogated by both epigenetic and pharmacologic c-Met inhibition. In patient-derived pancreatic cancer xenografts, nicotine treatment augmented tumor growth and metastasis; tumor lysates from nicotine-treated mice demonstrated elevated HGF expression by qRT-PCR and phospho-Met levels by ELISA. Similarly, elevated levels of phospho-Met in surgically resected pancreatic cancer specimens correlated with reduced overall survival. CONCLUSIONS Taken together, these data demonstrate a novel, microenvironment-dependent paracrine signaling mechanism by which nicotine exposure promotes the growth and metastasis of pancreatic cancer.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - Dongyu Zhang
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - Song Han
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - Brian S Black
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - Andrea E Knowlton
- Department of Periodontology and Oral Biology, University of Florida Health Science Center, Gainesville, Florida
| | - Adrian C Vlada
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida. North Florida/South Georgia Veterans Health System, University of Florida Health Science Center, Gainesville, Florida
| | - Kevin E Behrns
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - Ryan M Thomas
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida. North Florida/South Georgia Veterans Health System, University of Florida Health Science Center, Gainesville, Florida
| | - Xiaomin Lu
- Department of Biostatistics and Children's Oncology Group, University of Florida Health Science Center, Gainesville, Florida
| | - Chen Liu
- Department of Pathology, Immunology, Laboratory Medicine, Colleges of Medicine, Dentistry and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Thomas J George
- Department of Internal Medicine, University of Florida Health Science Center, Gainesville, Florida
| | - Steven J Hughes
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida
| | - Shannon M Wallet
- Department of Periodontology and Oral Biology, University of Florida Health Science Center, Gainesville, Florida
| | - Jose G Trevino
- Department of Surgery, University of Florida Health Science Center, Gainesville, Florida.
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Bahr NC, Sarosi GA, Meya DB, Bohjanen PR, Richer SM, Swartzentruber S, Halupnick R, Jarrett D, Wheat LJ, Boulware DR. Seroprevalence of histoplasmosis in Kampala, Uganda. Med Mycol 2015; 54:295-300. [PMID: 26527637 DOI: 10.1093/mmy/myv081] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/03/2015] [Indexed: 11/13/2022] Open
Abstract
Histoplasmosis is endemic to the Midwestern United States, but cases have been reported nearly worldwide. A 1970 study found 3.8% skin test sensitivity to Histoplasma capsulatum in Uganda but no systemic study of histoplasmosis exposure has occurred since the onset of the human immunodeficiency virus (HIV) pandemic. This study investigated the seroprevalence of H. capsulatum and sought previously undetected cases of histoplasmosis in Kampala, Uganda. Serum, cerebrospinal fluid (CSF) and/or urine specimens were obtained from HIV-infected persons with suspected meningitis. Specimens were tested for H. capsulatum IgG and IgM by enzyme immune assay and Histoplasma antigen. 147 of the 257 subjects who were enrolled had cryptococcal meningitis. Overall, 1.3% (2/151) of subjects were serum Histoplasma IgG positive, and zero of 151 were IgM positive. Antigen was not detected in any serum (n = 57), urine (n = 37, or CSF (n = 63) samples. Both subjects with serum Histoplasma IgG positivity had cryptococcal meningitis. Histoplasma capsulatum IgG was detected at low levels in persons with HIV/AIDS in Kampala, Uganda. Histoplasmosis is not widespread in Uganda but microfoci do exist. There appears to be no cross-reactivity between Cryptococcus neoformans and Histoplasma antigen testing, and cryptococcosis appears to be at most, a rare cause of positive Histoplasma IgG.
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Affiliation(s)
- Nathan C Bahr
- Infectious Diseases Institute, Makerere University, Kampala, Uganda Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
| | - George A Sarosi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul R Bohjanen
- Infectious Diseases Institute, Makerere University, Kampala, Uganda Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Ryan Halupnick
- Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
| | | | | | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota Center for Infectious Disease & Microbiology Translational Research, University of Minnesota, Minneapolis, Minnesota
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Delitto D, Black BS, Sorenson HL, Knowlton AE, Thomas RM, Sarosi GA, Moldawer LL, Behrns KE, Liu C, George TJ, Trevino JG, Wallet SM, Hughes SJ. The inflammatory milieu within the pancreatic cancer microenvironment correlates with clinicopathologic parameters, chemoresistance and survival. BMC Cancer 2015; 15:783. [PMID: 26498838 PMCID: PMC4619553 DOI: 10.1186/s12885-015-1820-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 10/16/2015] [Indexed: 01/05/2023] Open
Abstract
Background The tumor microenvironment impacts pancreatic cancer (PC) development, progression and metastasis. How intratumoral inflammatory mediators modulate this biology remains poorly understood. We hypothesized that the inflammatory milieu within the PC microenvironment would correlate with clinicopathologic findings and survival. Methods Pancreatic specimens from normal pancreas (n = 6), chronic pancreatitis (n = 9) and pancreatic adenocarcinoma (n = 36) were homogenized immediately upon resection. Homogenates were subjected to multiplex analysis of 41 inflammatory mediators. Results Twenty-three mediators were significantly elevated in adenocarcinoma specimens compared to nonmalignant controls. Increased intratumoral IL-8 concentrations associated with larger tumors (P = .045) and poor differentiation (P = .038); the administration of neoadjuvant chemotherapy associated with reduced IL-8 concentrations (P = .003). Neoadjuvant therapy was also associated with elevated concentrations of Flt-3 L (P = .005). Elevated levels of pro-inflammatory cytokines IL-1β (P = .017) and TNFα (P = .033) were associated with a poor histopathologic response to neoadjuvant therapy. Elevated concentrations of G-CSF (P = .016) and PDGF-AA (P = .012) correlated with reduced overall survival. Conversely, elevated concentrations of FGF-2 (P = .038), TNFα (P = .031) and MIP-1α (P = .036) were associated with prolonged survival. Conclusion The pancreatic cancer microenvironment harbors a unique inflammatory milieu with potential diagnostic and prognostic value.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Brian S Black
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Heather L Sorenson
- Department of Oral Biology, College of Dentistry, University of Florida Health Science Center, Gainesville, FL, 32610, USA.
| | - Andrea E Knowlton
- Department of Oral Biology, College of Dentistry, University of Florida Health Science Center, Gainesville, FL, 32610, USA.
| | - Ryan M Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA. .,North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
| | - George A Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA. .,North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
| | - Lyle L Moldawer
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Kevin E Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Chen Liu
- Department of Pathology, College of Medicine, University of Florida Health Science Center, Gainesville, FL, 32610, USA.
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL, 32610, USA.
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Shannon M Wallet
- Department of Oral Biology, College of Dentistry, University of Florida Health Science Center, Gainesville, FL, 32610, USA.
| | - Steven J Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Room 6116, Shands Hospital, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
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Affiliation(s)
- George A. Sarosi
- From Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
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Delitto D, Perez C, Black BS, Sorenson HL, Knowlton AE, Han S, Zhang D, Sarosi GA, Moldawer LL, Behrns KE, Liu C, George TJ, Thomas RM, Trevino JG, Wallet SM, Hughes SJ. Abstract 5028: CXCL10 within the tumor microenvironment induces gemcitabine resistance in pancreatic cancer cells. Immunology 2015. [DOI: 10.1158/1538-7445.am2015-5028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Delitto D, Pham K, Vlada AC, Sarosi GA, Thomas RM, Behrns KE, Liu C, Hughes SJ, Wallet SM, Trevino JG. Abstract 1466: Patient-derived xenograft models for pancreatic adenocarcinoma demonstrate retention of tumor morphology through the incorporation of murine stromal elements. Cancer Res 2015. [DOI: 10.1158/1538-7445.am2015-1466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Direct implantation of viable surgical specimens provides a representative preclinical platform in pancreatic adenocarcinoma (PC). Patient-derived xenografts consistently demonstrate retained tumor morphology and genetic stability. However, the evolution of the tumor microenvironment over time remains poorly characterized in these models. This work specifically addresses the recruitment and incorporation of murine stromal elements into expanding patient-derived PC xenografts, establishing the rapidity by which murine cells are integrated into networks of invading cancer cells. In addition, we provide methodology and observations in the establishment and maintenance of a patient-derived PC xenograft model. A total of 25 histologically confirmed pancreatic adenocarcinoma specimens were implanted subcutaneously into NOD-SCID mice. Patient demographics, staging, pathologic analysis and outcomes were analyzed. After successful engraftment of tumors, histologic and immunofluorescent analyses were performed on explanted tumors. PC specimens were successfully engrafted in 15 of 25 (60%) of attempts. Successful engraftment does not appear to correlate with clinicopathologic factors or patient survival. Tumor morphology is conserved through multiple passages and tumors retain metastatic potential. Interestingly, despite morphologic similarity between passages, human stromal elements do not appear to expand with invading cancer cells. Rather, desmoplastic murine stroma dominates the xenograft microenvironment after the initial implantation. Recruitment of stromal elements in this manner to support and maintain tumor growth represents a novel avenue for investigation into tumor-stromal interactions.
Citation Format: Daniel Delitto, Kien Pham, Adrian C. Vlada, George A. Sarosi, Ryan M. Thomas, Kevin E. Behrns, Chen Liu, Steven J. Hughes, Shannon M. Wallet, Jose G. Trevino. Patient-derived xenograft models for pancreatic adenocarcinoma demonstrate retention of tumor morphology through the incorporation of murine stromal elements. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1466. doi:10.1158/1538-7445.AM2015-1466
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Affiliation(s)
| | - Kien Pham
- University of Florida, Gainesville, FL
| | | | | | | | | | - Chen Liu
- University of Florida, Gainesville, FL
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Delitto D, Pham K, Vlada AC, Sarosi GA, Thomas RM, Behrns KE, Liu C, Hughes SJ, Wallet SM, Trevino JG. Patient-derived xenograft models for pancreatic adenocarcinoma demonstrate retention of tumor morphology through incorporation of murine stromal elements. Am J Pathol 2015; 185:1297-303. [PMID: 25770474 PMCID: PMC4419203 DOI: 10.1016/j.ajpath.2015.01.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/05/2015] [Accepted: 01/23/2015] [Indexed: 01/05/2023]
Abstract
Direct implantation of viable surgical specimens provides a representative preclinical platform in pancreatic adenocarcinoma. Patient-derived xenografts consistently demonstrate retained tumor morphology and genetic stability. However, the evolution of the tumor microenvironment over time remains poorly characterized in these models. This work specifically addresses the recruitment and incorporation of murine stromal elements into expanding patient-derived pancreatic adenocarcinoma xenografts, establishing the integration of murine cells into networks of invading cancer cells. In addition, we provide methods and observations in the establishment and maintenance of a patient-derived pancreatic adenocarcinoma xenograft model. A total of 25 histologically confirmed pancreatic adenocarcinoma specimens were implanted subcutaneously into nonobese diabetic severe combined immunodeficiency mice. Patient demographics, staging, pathological analysis, and outcomes were analyzed. After successful engraftment of tumors, histological and immunofluorescence analyses were performed on explanted tumors. Pancreatic adenocarcinoma specimens were successfully engrafted in 15 (60%) of 25 attempts. Successful engraftment does not appear to correlate with clinicopathologic factors or patient survival. Tumor morphology is conserved through multiple passages, and tumors retain metastatic potential. Interestingly, despite morphological similarity between passages, human stromal elements do not appear to expand with invading cancer cells. Rather, desmoplastic murine stroma dominates the xenograft microenvironment after the initial implantation. Recruitment of stromal elements in this manner to support and maintain tumor growth represents a novel avenue for investigation into tumor-stromal interactions.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Kien Pham
- Department of Pathology, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Adrian C Vlada
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida; North Florida/South Georgia Veterans Health System, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Ryan M Thomas
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida; North Florida/South Georgia Veterans Health System, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Kevin E Behrns
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Chen Liu
- Department of Pathology, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Steven J Hughes
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Shannon M Wallet
- Department of Periodontology and Oral Biology, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Jose G Trevino
- Department of Surgery, Colleges of Medicine, Dentistry, and Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida.
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Loftus TJ, Kresak JL, Gonzalo DH, Sarosi GA, Behrns KE. Duodenal gangliocytic paraganglioma: A case report and literature review. Int J Surg Case Rep 2015; 8C:5-8. [PMID: 25600615 PMCID: PMC4353939 DOI: 10.1016/j.ijscr.2015.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/03/2015] [Indexed: 02/02/2023] Open
Abstract
Differentiation between GP and GIST alters treatment algorithms. Primary management of duodenal GP consists of resection with negative margins. Surveillance alone is safe and effective following resection with negative margins. For regionally advanced disease, consider adjuvant radiotherapy.
Introduction Gangliocytic paraganglioma is a rare tumor that is most commonly located in the duodenum. At presentation, it may be confused with a gastrointestinal stromal tumor (GIST), but distinguishing between these tumors is critical because the natural history and treatment of these two tumors differs markedly. Duodenal gangliocytic paraganglioma typically exhibits benign behavior with occasional regional lymph node metastasis and no reports of tumor associated deaths. Recurrence after resection is rare. Presentation of case A 50 year-old male presented with melena and hemoglobin concentration of 4.6 g/dl. Esophagogastroduodenoscopy demonstrated a submucosal mass in the third portion of the duodenum with no active bleeding. CT scan identified no regional lymphadenopathy or distant metastasis. The tumor was resected through a longitudinal duodenotomy with negative margins. Discussion Endoscopic resection of duodenal gangliocytic paraganglioma appears to be safe and effective when tumor may be removed in its entirety by this method. If the tumor is not suspended by a stalk or there is suspicion for regional lymph node disease then surgical management is preferred. Radiation oncologists at high volume centers have endorsed utilization of adjuvant radiotherapy to the postsurgical bed in cases involving lymph node metastasis. Utilization of chemotherapy for management of this disease has not been reported. Conclusion Localized duodenal gangliocytic paragangliomas are best managed by resection with negative margins. In cases in which the tumor is resected with negative margins, it appears to be safe to embark on a course of surveillance and forego adjuvant therapy.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, the University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Jesse L Kresak
- Department of Pathology, the University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - David H Gonzalo
- Department of Pathology, the University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - George A Sarosi
- Department of Surgery, the University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Kevin E Behrns
- Department of Surgery, the University of Florida College of Medicine, Gainesville, FL 32610, USA.
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Sarosi GA, Silver MA, Ben-David K, Behrns KE. Training outcomes of preliminary surgical residents in a university and Veterans Affairs surgical residency. JAMA Surg 2014; 149:1127-32. [PMID: 25207827 DOI: 10.1001/jamasurg.2014.2054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Nearly 1400 medical students enter preliminary surgical residency each year; placing some of these students into categorical surgical training is an important component of building the future surgical workforce. OBJECTIVES To examine the training outcomes of preliminary residents in a university and Veterans Affairs surgical residency and to test the hypothesis that characteristics of these residents could be identified that would predict successful placement into categorical general surgical residency. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort of 66 nondesignated preliminary surgical residents who entered a research-intensive, university-based surgical training program with significant Veterans Affairs hospital experience between 2004 and 2012. MAIN OUTCOMES AND MEASURES Placement of preliminary residents into a categorical general surgical residency. RESULTS Of 66 nondesignated preliminary residents enrolled in our program during the study period, 57 completed a postgraduate year (PGY) 1 and 22 completed a PGY-2. A total of 21 residents (32%) secured categorical general surgical positions, 8 of 57 (14%) after PGY-1 and 13 of 22 (59%) after PGY-2, a significantly different rate (P < .001). Predictors of success in obtaining a categorical position included a PGY-2, United States Medical Licensing Examination step 2 score, year 1 American Board of Surgery In-Training Examination score, class rank, and prior graduate medical education. By multivariable analysis, only the PGY-2 was significant (P < .03). Residents who obtained categorical surgical positions after 1 preliminary year had significantly higher United States Medical Licensing Examination scores (mean [SD] step 1 score, 235.4 [23.5] vs 206.3 [16.2]; P < .02; step 2 score, 239.3 [21.2] vs 218.5 [16.1]; P < .05) but did not have higher year 1 American Board of Surgery In-Training Examination percentiles (mean [SD], 63.3 [33.3] vs 47.3 [30.8]; P < .34). CONCLUSIONS AND RELEVANCE Performing a PGY-2 preliminary year increases the chance for a preliminary surgical resident to obtain a place in a categorical surgical residency. Programs that offer preliminary positions should consider offering both PGY-1 and PGY-2 positions, because the PGY-2 increases the categorical surgical placement rate, especially for residents with lower test scores.
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Affiliation(s)
- George A Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville2North Florida/South Georgia Veterans Affairs Medical Center, Gainesville
| | - Michele A Silver
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Kfir Ben-David
- Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Kevin E Behrns
- Department of Surgery, University of Florida College of Medicine, Gainesville
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Sarosi GA. A missed opportunity-a near disaster. Diagnosis (Berl) 2014. [PMID: 29539995 DOI: 10.1515/dx-2013-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Community acquired pneumonia (CAP) is a common medical problem. Over 1.5 million patients annually will be diagnosed with CAP and treated with empiric therapy initially. The vast majority of patients will improve with a single course broad spectrum antimicrobial agent. Rarely a patient will not improve and some may progress on this regimen. Giving a second course of broad spectrum antimicrobial agent is not warranted until further evaluation is performed to look for the unusual cause of CAP. Blastomycosis is a regionally common community acquired fungal infection. When potential exposure of the patient to an area of high endemicity is recognized appropriate diagnostic studies should be performed.
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Affiliation(s)
- George A Sarosi
- 1Professor of Medicine, University of Minnesota, VA Medical Center, One veterans Drive, Minneapolis, MN 55417, USA
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Han S, Lee CW, Trevino JG, Hughes SJ, Sarosi GA. Autocrine extra-pancreatic trypsin 3 secretion promotes cell proliferation and survival in esophageal adenocarcinoma. PLoS One 2013; 8:e76667. [PMID: 24146905 PMCID: PMC3795734 DOI: 10.1371/journal.pone.0076667] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/24/2013] [Indexed: 01/18/2023] Open
Abstract
Trypsin or Tumor associated trypsin (TAT) activation of Protease-activated receptor 2 (PAR-2) promotes tumor cell proliferation in gastrointestinal cancers. The role of the trypsin/PAR-2 network in esophageal adenocarcinoma (EA) development has not yet been investigated. The aim of this study is to investigate the role of trypsin/PAR-2 activation in EA tumorogenesis and therapy. We found that esophageal adenocarcinoma cells (EACs) and Barrett’s Metaplasia (BART) expressed high levels of type 3 extra-pancreatic trypsinogen (PRSS3), a novel type of TAT. Activity of secreted trypsin was detected in cultured media from EA OE19 and OE33 cultures but not from BART culture. Surface PAR-2 expression in BART and EACs was confirmed by both flow cytometry and immunofluorescence. Trypsin induced cell proliferation (∼ 2 fold; P<0.01) in all tested cell lines at a concentration of 10 nM. Inhibition of PAR-2 activity in EACs via the PAR-2 antagonist ENMD (500 µM), anti-PAR2 antibody SAM-11 (2 µg/ml), or siRNA PAR-2 knockdown, reduced cell proliferation and increased apoptosis by up to 4 fold (P<0.01). Trypsin stimulation led to phosphorylation of ERK1/2, suggesting involvement of MAPK pathway in PAR-2 signal transduction. Inhibition of PAR-2 activation or siRNA PAR-2 knockdown in EACs prior to treatment with 5 FU reduced cell viability of EACs by an additional 30% (P<0.01) compared to chemotherapy alone. Our data suggest that extra-pancreatic trypsinogen 3 is produced by EACs and activates PAR-2 in an autocrine manner. PAR-2 activation increases cancer cell proliferation, and promotes cancer cell survival. Targeting the trypsin activated PAR-2 pathway in conjunction with current chemotherapeutic agents may be a viable therapeutic strategy in EA.
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Affiliation(s)
- Song Han
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Constance W. Lee
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Jose G. Trevino
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Steven J. Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - George A. Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, United States of America
- North Florida/South Georgia VA Medical Center, Gainesville, Florida, United States of America
- * E-mail:
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Abstract
The rate of elective surgery for peptic ulcer disease has been declining steadily over the past 3 decades. During this same period, the rate of emergency ulcer surgery rose by 44%. This means that the gastrointestinal surgeon is likely to be called on to manage the emergent complications of peptic ulcer disease without substantial experience in elective peptic ulcer disease surgery. The goal of this review is to familiarize surgeons with our evolving understanding of the pathogenesis, epidemiology, presentation, and management of peptic ulcer disease in the emergency setting, with a focus on peptic ulcer disease-associated bleeding and perforation.
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Affiliation(s)
- Constance W Lee
- Department of Surgery, University of Florida College of Medicine, 1600 Southwest Archer Road, PO Box 100109, Gainesville, FL 32610-0109, USA
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