Assessing the Impact of Powerful Experiences During Anesthesia Residency Training

BACKGROUND

Formative events during training help shape professional identity and may impact well-being. This study sought to identify formative experiences during anesthesia residency and measure their perceived impact on well-being.

METHODS

A 24-item survey exploring the frequency and perceived impact of formative events was developed through a rigorous process involving a literature search, consultation with medical education experts, resident focus groups, graduate interviews, and pilot testing. All 80 anesthesiology residents at Johns Hopkins University were invited to participate. We measured the frequency of event exposure and perceived impact on well-being.

RESULTS

Seventy-six residents (95%) completed the survey. Event exposure rate ranged from 56.6% to 100%. Events with greatest relative impact (RI) overall included leaving work earlier than expected (RIoverall = 85.8), a patient expresses genuine gratitude (RIoverall = 80.2), identifying a faculty role model (RIoverall = 75.7), and having a patient die under my care (RIoverall = 75.6). There was no statistically significant difference on RI for positive versus negative events. The perceived impact of events on well-being varied by gender.

CONCLUSIONS

This work provides clarity for residency program leaders and educators about the commonly experienced formative events that have the greatest perceived impact on resident well-being. These results may inform curricular planning and can suggest times when trainees may need attention or support. Future research should evaluate the direct impact of formative events on well-being and the success of related interventions.

Synthesis and structure-activity relationship studies of small molecule disruptors of EWS-FLI1 interactions in Ewing's sarcoma

EWS-FLI1 is an oncogenic fusion protein implicated in the development of Ewing's sarcoma family tumors (ESFT). Using our previously reported lead compound 2 (YK-4-279), we designed and synthesized a focused library of analogues. The functional inhibition of the analogues was measured by an EWS-FLI1/NR0B1 reporter luciferase assay and a paired cell screening approach measuring effects on growth inhibition for human cells containing EWS-FLI1 (TC32 and TC71) and control PANC1 cell lines devoid of the oncoprotein. Our data revealed that substitution of electron donating groups at the para-position on the phenyl ring was the most favorable for inhibition of EWS-FLI1 by analogs of 2. Compound 9u (with a dimethylamino substitution) was the most active inhibitor with GI50 = 0.26 ± 0.1 μM. Further, a correlation of growth inhibition (EWS-FLI1 expressing TC32 cells) and the luciferase reporter activity was established (R(2) = 0.84). Finally, we designed and synthesized a biotinylated analogue and determined the binding affinity for recombinant EWS-FLI1 (Kd = 4.8 ± 2.6 μM).

Investigation of the insulin-like growth factor-1 signaling pathway in localized Ewing sarcoma: a report from the Children's Oncology Group

BACKGROUND

The insulin-like growth factor-1 (IGF-1) signaling pathway plays an important role in the pathology of Ewing sarcoma (ES). Retrospective studies have suggested that levels of IGF-1 and IGF binding protein 3 (IGFBP-3) are correlated with the outcome of patients with ES.

METHODS

The IGF-1 signaling pathway was investigated prospectively in 269 patients who had localized, previously untreated ES. Serum samples were obtained at diagnosis, and concentrations of IGF-1 and IGFBP-3 were determined by enzyme-linked immunosorbent assays. In addition, immunohistochemistry (IHC) was performed to assay for phosphorylated p70S6 kinase, protein kinase B (Akt), and forkhead box protein O1 (FOXO1) and to determine the presence of protein tyrosine phosphatase-L1 (PTPL1). IHC findings along with IGF-1 and IGFBP-3 concentrations were correlated with age, tumor location, sex, event-free survival, and overall survival.

RESULTS

Patients aged >18 years tended to have higher levels of IGF-1 (P = .10), lower levels of IGFBP-3 (P = .16), and decreased IGFBP-3:IGF-1 ratios (P = .01). No correlations were observed between sex, tumor location, or outcomes and concentrations of IGF-1 or IGFBP-3. Phosphorylation of p70S6 kinase, Akt, and FOXO1 was detected in the majority of patient tissues but was not associated with age, sex, or tumor location. PTPL1 was present in >80% of tumors and also was not correlated with age, sex, or tumor location. There was no difference in survival with respect to the presence of phosphorylated p70S6 kinase, phosphorylated FOXO1, phosphorylated Akt, or PTPL1.

CONCLUSIONS

The baseline IGFBP-3:IGF-1 ratio was correlated with age but did not affect the outcomes of patients with ES. The authors concluded that additional investigation of the IGF-1 pathway is warranted in patients with ES, and especially in those who have received treatment with IGF-1 receptor antibody inhibitors.

Management of coexisting coronary artery and asymptomatic carotid artery disease: report of a series of patients treated with coronary bypass alone

BACKGROUND

A retrospective chart review of 94 patients with asymptomatic high-grade carotid stenosis undergoing coronary bypass (and valve replacement in some cases) was performed to determine whether significant carotid lesions can be safely ignored in patients undergoing cardiac surgical procedures. These operations were performed during a 2-year period.

PATIENTS AND METHODS

There were 55 men and 39 women, with an age range of 37-89 years. Seventy-one patients had unilateral high-grade carotid stenosis, 17 patients had bilateral high-grade lesions, and six patients had unilateral high-grade stenosis and contralateral occlusion. Associated medical problems were recorded and short-term follow-up was obtained.

RESULTS

There was one perioperative stroke and no deaths in this group of patients.

CONCLUSIONS

Although these data indicate that high-grade carotid stenoses may be safely ignored during cardiac surgical procedures, a multicentre prospective randomized trial is needed to determine the appropriate treatment of the patient with coexisting carotid and coronary artery disease.

Elevated AGE-modified ApoB in sera of euglycemic, normolipidemic patients with atherosclerosis: relationship to tissue AGEs

BACKGROUND

Advanced glycation endproducts (AGEs) are implicated in the pathogenesis of atherosclerotic vascular disease of diabetic and nondiabetic etiology. Recent research suggests that advanced glycation of ApoB contributes to the development of hyperlipidemia. AGE-specific receptors, expressed on vascular endothelium and mononuclear cells, may be involved in both the clearance of, and the inflammatory responses to AGEs. The aim of this study was to examine whether there is a relationship between serum AGE-ApoB and AGEs in arterial tissue of older normolipidemic nondiabetic patients with occlusive atherosclerotic disease, compared with age-matched and younger asymptomatic persons.

MATERIALS AND METHODS

Serum AGE-ApoB was measured by ELISA in 21 cardiac bypass patients. Furthermore, an AGE-specific monoclonal antibody, and polyclonal antibodies against anti-AGE-receptor (anti-AGE-R) 1 and 2 were used to explore the localization and distribution of AGEs and AGE-R immunoreactivity (IR) in arterial segments excised from these patients.

RESULTS

Serum AGE-ApoB levels were significantly elevated in the asymptomatic, older population, compared with those in young healthy persons (259 +/- 24 versus 180 +/- 21 AGE U/mg of ApoB, p < 0.01). Higher AGE-ApoB levels were observed in those patients with atherosclerosis (329 +/- 23 versus 259 +/- 24 AGE U/mg ApoB, p < 0.05). Comparisons of tissue AGE-collagen with serum AGE-ApoB levels showed a significant correlation (r = 0.707, p < 0.01). In early lesions, AGE-IR occurred mostly extracellularly. In fatty streaks and dense, cellular atheromatous lesions, AGE-IR was visible within lipid-containing smooth muscle cells and macrophages, while in late-stage, acellular plaques, AGE-IR occurred mostly extracellularly. AGE-R1 and -R2 were observed on vascular endothelial and smooth-muscle cells and on infiltrating mononuclear cells in the early-stage lesions, whereas in dense, late-stage plaques, they colocalized mostly with lipid-laden macrophages. On tissue sections, scoring of AGE-immunofluorescence correlated with tissue AGE and plasma AGE-ApoB.

CONCLUSIONS

(1) The correlation between arterial tissue AGEs and circulating AGE-ApoB suggests a causal link between AGE modification of lipoproteins and atherosclerosis. AGE-specific receptors may contribute to this process. (2) Serum AGE-ApoB may serve to predict atherosclerosis in asymptomatic patients.

Indications for distal arterial reconstruction in the presence of palpable pedal pulses

Eight patients with severe pedal ischemia in the presence of palpable foot pulses are described. All had atherosclerosis, and seven patients also had diabetes. There were two anatomic patterns of disease, including supramalleolar obstruction with reconstitution of pulsatile flow in three patients and segmental occlusion of the pedal vessels in five. All patients underwent arterial reconstructive surgery. Patency was sustained in six patients, with limb salvage in five and below-knee amputation in one patient for persistent necrosis and infection of an open amputation. Of the two eventual bypass failures, a transmetatarsal amputation continued to heal in one patient, and the other required amputation below the knee. Palpable pedal pulses and satisfactory ankle/brachial indexes did not rule out the presence of surgically correctable distal arterial occlusive disease. Therefore arteriography is indicated in any patient with persistent forefoot ischemia that fails to respond to conservative measures. The safety and patency of the distal reconstructive procedures performed in this series suggest that salvage of weight-bearing tissue and rapid healing, as well as limb salvage, are legitimate indications for revascularization.

Perioperative noninvasive hemodynamic ankle indices as predictors of infrainguinal graft patency

Of 129 femoropopliteal bypasses, 40 closed in 0 to 42 months. Early and late closures were not predicted by pre- or postoperative ankle/brachial pressure index (ABPI) or ankle pulse volume recording amplitude (APVR) or their increments (delta). Of 141 femorotibial bypasses, 60 closed in 0 to 12 months, with 46 closing early (less than 1 month). Early failure occurred in 19 of 52 limbs (37%) with pre-ABPI less than 0.2 and 17 of 89 limbs (19%) with pre-ABPI greater than 0.2 (p less than 0.025). Similar significant differences in early patency occurred between limbs with pre-APVR less than 5 and greater than 5 mm (29 of 94 [34%] vs. 7 of 47 [15%], respectively). Late closure was not predicted by either value. Thus in the 44 limbs with pre-ABPI greater than 0.2 and pre-APVR greater than 5 mm, only 11 grafts closed (25%), whereas if pre-ABPI was less than 0.2 or pre-APVR less than 5 mm, 49 of 97 grafts (51%) occluded within 17 months (p less than 0.025). Postoperative or delta indices had no predictive value. Preoperative ABPI less than 0.2 or APVR less than 5 mm was associated with twice the risk of early femorotibial graft closure; however, cumulative life-table patency was still 39% at 24 months.

Gonorrhoea in patients with scabies

242 patients with scabies were examined for gonorrhoea at the Municipal Hospital of Copenhagen over a one-year period. We found asymptomatic gonorrhoea in 2% of the male patients and 12%. of the female patients. The incidence of gonorrhoea in female patients with scabies is thus higher than in other routinely examined groups of patients (Andersen and Nielsen, 1974; Gregersen, 1972; Hansen and Lange, 1973; Nielsen, 1974; Starck, Bygdeman, Eriksson, Heinerz, and Moberg, )971). Our suggestion is that all patients with scabies, male as well as female, should be examined routinely for gonorrhoea.