2.18 Characterization of a Novel Mutation in Fibrolamellar Hepatocellular Carcinoma

Posted on December 22, 2014

K. M. Riggle1, R. S. Yeung1, H. L. Kenerson1, K. J. Riehle2  1University Of Washington,Surgery,Seattle, WA, USA 2Seattle Children’s Hospital,General And Thoracic Surgery,Seattle, WA, USA

Introduction:  Hepatocellular carcinoma (HCC) is a heterogenous disease that commonly arises in a background of cirrhosis.  Fibrolamellar HCC (FL-HCC) is a subtype of HCC occurring in children and young adults in the absence of known liver disease.  Currently, there is no effective therapy for unresectable or metastatic FL-HCC.  Recent genomic analysis identified a recurrent mutation in FL-HCC involving a deletion on chromosome 19.  The mutation results in a common chimeric transcript containing the 5’-region of a heat shock protein (DNAJB1) fused to the catalytic subunit of protein kinase A (PRKACA).  We sought to characterize this chimeric protein and its effects on PKA activity in human FL-HCC. 

Methods:  We prepared tissue lysates from four snap-frozen FL-HCC samples along with paired, non-tumor liver tissues.  PRKACA expression was determined by immunoblot analysis.  PKA activity was determined via a radioactive kinase assay in the presence of cAMP, a known activator of PKA, with and without PKI, a specific inhibitor of PKA accounting for background activity.  RNA was extracted using TRIZOL reagent, and used to create cDNA for qRT-PCR analysis of the mutant transcript.     

Results:  We confirmed that all tumor samples expressed a 46-kDa fusion gene product in addition to the wild-type 41-kDa PKA protein.  The paired normal liver samples only expressed the wild-type protein.  Further, the mutant protein was not detected in ‘classic’ HCCs nor cancer-associated fibroblasts isolated from a case of FL-HCC.  Using qPCR we found that the FL-HCC tumors expressed the chimeric transcript at levels that were 10.59±4.2 fold higher than normal liver (p = 0.016).  Basal PKA activities from freshly lysed tumors and paired livers were not significantly different, but cAMP-stimulated PKA activity was significantly higher in FL-HCC tumors when compared to normal liver.  In a dose response experiment, the PKA activity in FL-HCC was 3.62, 5.52, and 6.41 pmol/min/mg (vs. normal liver with PKA activity of 2.60, 3.14, and 4.95 pmol/min/mg) at cAMP concentrations of 0.05, 0.5, and 5 uM respectively.

Conclusion:  Our data verify the unique expression of the DNAJB1-PRKACA fusion protein in all FL-HCC samples tested, but absent in the adjacent non-tumor liver and non-FL-HCCs.   Further, the lack of mutant protein expression in fibroblasts derived from FL-HCC highlights the primary effects of the mutation on transformed hepatocytes and not the stromal component.  The expression of the mutant transcript was significantly greater than that of the native PKA indicative of higher intrinsic promoter activity of DNAJB1 compared to that of PRKACA.  Importantly, PKA activity in the FL-HCCs remains cAMP-dependent but with increased sensitivity to cAMP without evidence of enhanced basal activity.  These findings suggest that the expression of DNAJB1-PRKACA in FL-HCC leads to over-activation of PKA under conditions of cAMP production, which may contribute to tumor development.

2.19 Incidental Gallbladder Pathology in Patients Undergoing Cholecystectomy

Posted on December 22, 2014

R. A. Rodriguez1, H. Overton2, K. Morris1, I. Nir1, M. Williamson3, A. Rajput1  1University Of New Mexico,Division Of Surgical Oncology, Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico,School Of Medicine,Albuquerque, NM, USA 3University Of New Mexico,Department Of Radiology,Albuquerque, NM, USA

Introduction: The highest incidence rates of gallbladder cancer (GBC) in the continental United States are in New Mexico and amongst the minority-majority Native American and Hispanic populations. This cancer is often fatal as most patients present with advanced stages of disease. Early diagnosis remains a challenge as specific signs and symptoms are absent. Early stages of disease, which have a more favorable outcome, are often found incidentally at time of cholecystectomy. The purpose of this study was to determine the incidence of gallbladder pathology in patients undergoing cholecystectomy and to correlate any pre-operative radiographic findings with the pathology.

Methods: Healthsystem database was queried for patients who underwent cholecystectomy between 1991 and 2013. A total of 6793 patients were identified. Data extracted included: demographics, previous ultrasound report, surgical and pathologic reports. Pathologic findings including gallbladder cancer, dysplasia, metaplasia and polyps were recorded. Radiographic reports were reviewed to determine if pre-operative finding predicted final pathologic diagnosis.

Results: There were 4993 (74%) females. Female patients were more likely to present at an older age (52.5) compared to males (45.4); patients who were found to have GBC were more likely to be older (73.4). Out of a total of 17 GBCs identified, 5 (29%) patients were known to have malignancy prior to surgery and 12 (71%) were discovered to have malignancy on pathologic analysis. Pre-operative radiographic findings correlated to pathological findings in only 3 (18%) cases. GB pathology stratified by ethnic group is shown in table 1. GB pathology was more likely to be found in Hispanics and Native Americans although the incidence of pathology was not statistically significant amongst ethnicities in our data set.

Conclusion: Although rare, gallbladder pathology is incidentally found at the time of cholecystectomy.  The diagnosis of cancer, dysplasia, metaplasia and polyps was more common in Hispanics and Native Americans as compared to non-Hispanic whites. Although ultrasonography continues to be a good diagnostic method for gallstones and cholecystitis, its utility in other gallbadder pathologies remains unproven. There is a need to develop new screening and diagnostic methods for patients with gallbladder cancer.

 

2.20 Development of Theranostic Mesoporous Silica Nanoparticles for Pancreatic Cancer

Posted on December 22, 2014

D. S. Pender1, A. Khanal1, S. Hudson1, L. McNally1  1University Of Louisville,Louisville, KY, USA

Introduction: Modern methods of pancreatic cancer diagnosis and treatment are severely lacking and have failed to provide effectual treatment options for patients. The root cause of this inadequacy stems from the hypovascularized nature of pancreatic cancer, making traditional chemotherapeutics and cancer detecting contrast agents nearly obsolete. A potential solution for tumor-targeting difficulties is through the implementation of nanotechnology, specifically targeting ligand capped, theranostic nanoparticles. We hypothesize that pH-responsive chitosan-capped mesoporous silica nanoparticles (MSNs) with the targeting ligand, urokinase plasminogen activator (UPA) will serve as theranostic agents for treatment and diagnosis of pancreatic cancer.

Methods: MSNs were synthesized by employing cetyl trimethylammonium bromide (CTAB), tetraethyl orthosilicate (TEOS) and chitosan through the sol-gel method. The synthesized MSNs were characterized by transmission electron microscopy (TEM) and zeta-potential measurements. Afterwards, gemzar chemotherapeutic drug was encapsulated into these nanoparticles to observe the pH dependent release profiles in vitro. Furthermore, MSNs were tagged with UPA to increase the binding efficiency of these nanoparticles towards the pancreatic tumor cells (S2CP9 and S2VP10). The binding efficiency of both tagged and non-tagged MSNs was observed at various pHs (7.4 to 6.5) by employing fluorescence microscopy, Odyssey infrared imaging and tissue phantoms. For that, various types of dyes were used, such as, rhodamine B and indocyanine green (ICG). Finally, UPA-tagged MSNs with ICG were injected into mice infected with S2CP9 tumors cells to observe the distribution of these nanoparticles in-vivo through multispectral photoacoustic Tomography system (MSOT).

Results: TEM pictures showed that the synthesized MSN had a size around 120 nm.  Zeta-potential measurements revealed that charge density of MSN was dependent on pH.  The release experiments showed that these nanoparticles were pH-sensitive because the release of gemazar depended on the pH. Gemzar released ~2x the quantity from MSNs at pH 6.5 in comparison to pH 7.4.  Fluorescence microscopy, Odyssey infrared imaging and tissue phantoms showed that uptake of MSNs by pancreatic tumor cells depended on the pH and tagging of UPA. Lowering pH and tagging a ligand drastically increased the uptake of MSNs in pancreatic tumor cell in vitro. Specifically in tissue phantoms, UPA-ICG loaded MSNs at pH 6.5 demonstrated 20X and 7X more cell signal than without ligand or at pH 7.4, respectively.  Furthermore, UPA-ICG loaded MSNs were successfully detected in orthotopic pancreatic tumor of mice within 6 hours of imaging time by MSOT.

Conclusion: UPA tagged, pH sensitive MSNs demonstrate potential as a theranostic nanoparticle for pancreatic cancer.

 

17.20 Defining success after parathyroidectomy for secondary hyperparathyroidism: Use of KDIGO guidelines

Posted on December 22, 2014

S. C. Oltmann1, T. M. Madkhali2, H. Chen2, R. S. Sippel2, D. F. Schneider2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction
Patients with end stage renal disease (ESRD) suffer from hypocalcemia and secondary hyperparathyroidism (SPHPT).  Therefore, defining recurrence or persistence after parathyroidectomy (PTX) using calcium values alone becomes problematic.  The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines provide target ranges for serum calcium (Ca: 8.4 to 10.2 mg/dL), phosphorous (Phos: 2.5 to 4.6 mg/dL) and parathyroid hormone (PTH: 130 to 600 pg/mL) levels for those patients with ESRD requiring dialysis.  The study purpose is to see if KDIGO targets, which often determine need for initial surgical intervention, are also appropriate to define disease persistence or recurrence in SHPT.
Methods
A retrospective review of a prospective endocrine surgery database was performed.  Included patients had SHPT, due to ESRD, were on dialysis and underwent PTX.  Ca, Phos and PTH were classified as below, within, or above the KDIGO targets at various pre and post-operative time points.
Results
Between 2000 and 2013, 36 patients with SHPT met inclusion criteria. Mean age was 44±SEM2.1 years. 42% were females. Subtotal PTX was performed in 89%, with 11% undergoing total PTX. Follow-up time was 54±7 months. 8 patients (22%) required additional procedures to address recurrent and/or persistent SHPT. 28 patients (76%) of were alive at last follow-up, with estimated survival at 1 year (100%), 2 years (94%), 5 years (82%) and 10 years (65%) calculated. Sensipar use at last follow-up was noted in 2 patients (5%).  At time of last follow up, 46% of patients had Phos levels, and 17% had PTH levels still above the KDIGO ranges (Table).
Factors associated with need for re-operation were assessed. Patient PTH levels within or above target at time of first post-operative visit were associated with a higher rate of reoperation(p<0.01).  At the time of last follow-up, Ca levels with respect to KDIGO ranges were not associated with higher reoperation rates (p=0.33), but higher Phos (p=0.054), PTH (p<0.001) levels were associated with increased rates of reoperation.
Conclusions
Of the various KDIGO laboratory indices for patients with ESRD on dialysis with SHPT, PTH and Phos levels above target were associated with additional surgical intervention.  However, a significant number of patients had laboratory indices above suggested ranges at last follow-up, suggesting many more patients residual or recurrent disease than have undergone reoperation, suggesting that there are many patients who may benefit from more aggressive surgical or medical management.

18.02 A Novel Case Simulator to Help Predict Completion of Plastic Surgery Core Operative Requirements

Posted on December 22, 2014

T. N. Ballard1, W. Pozehl2, T. R. Grenda1, M. S. Daskin2, J. Seagull3, A. M. Cohn2,4, S. J. Kasten1, R. M. Reddy1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Industrial And Operations Engineering,Ann Arbor, MI, USA 3University Of Michigan Medical School,Ann Arbor, MI, USA 4University Of Michigan,Center For Healthcare Engineering And Patient Safety,Ann Arbor, MI, USA

Introduction:  On July 1, 2014, the new Accreditation Council for Graduate Medical Education (ACGME) operative minimum requirements for plastic surgery residents became effective. Under the updated guidelines, the resident “assistant” option is no longer used, and up to two residents can count a case as “surgeon” if each is present for and participates in all of the critical portions of the operation. Given that specific operative case arrival/frequency and resident distribution are not equitable, we sought to assess the applicability of a case distribution simulation model to determine the threshold case volume required to certify plastic surgery residents using the new guidelines. The treatment of occlusal injuries was utilized as an example procedure.

Methods:  A novel computer model was created to simulate annual case distribution based on annual case volume, number of trainees, and rotation length, and assess for a program’s ability to train all residents each year. The simulator varies the annual volume based on historical data provided (above and below the mean).  Single institution occlusal injury treatment data (2010-2013) were used to simulate case distribution for 10,000 “simulated” years to indicate the frequency of one or more senior residents achieving the minimum number of cases during their final two years of training. 

Results: The illustrated program currently has three residents per year, and the average number of occlusal injuries treated was 27.3 ± 6.6 over a four-year period. The ACGME requires all plastic surgery residents to treat at least eight occlusal injuries during training. If the final two years of a resident’s training are simulated, with up to two residents able to count each case and each resident having equal access to all cases, all three chiefs would meet the requirement for occlusal injury treatment 98.2% of the time. If the program expands to four residents, the likelihood of all residents meeting requirements decreases to 87.1%.The minimum number of cases per year necessary to certify three and four residents 100% of the time is 28 and 29, respectively.

Conclusion: Under the new ACGME guidelines for plastic surgery, residents log only “surgeon” cases, and up to two residents may count each case. However, the number of annual cases needed each year to fulfill requirements is greater than simply the number of residents multiplied by the number of required cases (i.e., 3×8 ≠24), due to unpredictable and inequitable case occurrence.  The simulator enables residency programs to analyze the impact of the new operative requirements on the ability to certify current residents and the effect of expanding the number of residents. The broad applicability of such a model is just being realized.

18.03 Impact of “Home Call” on Residency Training in an Otolaryngology-Head & Neck Surgery Program: A Pilot Study

Posted on December 22, 2014

L. Caulley3, J. Vaccani2,3  2Children’s Hospital Of Eastern Ontario,Ottawa, ONTARIO, Canada 3University Of Ottawa,Ottawa, Ontario, Canada

Introduction: Recent studies demonstrated that duty hour restrictions have a positive impact on the quality of life in residency training programs. However, objective data on the necessity for resident duty hour restrictions or the impact of resident duty hours on the academic portion of residency training for surgical residents in a home call setting has yet to be established in the literature.  This was a pilot study to evaluate home call in an Otolaryngology-Head and Neck Surgery residency program and its impact on resident education and well-being using subjective and objective parameters.  

Methods: All PGY 2-4 residents in the University of Ottawa Department of Otolaryngology- Head and Neck Surgery (n=7) were invited to complete an electronic log of their encounters while on night call. Residents were asked to characterize the time elapsed and nature of the call event as either urgent or non-urgent according to a guideline provided by the authors. In addition, all residents completed the Stanford Sleepiness Scale (SSS) on the day of call being investigated and the post-call day to establish a subjective proxy of resident well-being. 

Results:Thirty-six call logs were analyzed for the pilot study. Fifty percent of residents qualified for a post-call day according to the Professional Association of Residents of Ontario guidelines. Residents received an average of 6.7 calls per night (5pm -7am), of which 76% of calls were classified as non-urgent. The amount of time elapsed managing non-urgent and urgent issues was 2.36 and 2.20 times greater in residents who qualified for a post-call day as compared to those who did not qualify for a post-call day, respectively. In order to estimate the effect of call on sleepiness, accounting for pre-call sleepiness score and the fact that there were multiple measurements made on each resident, a linear mixed effects analysis of covariance model was fitted. On average, sleepiness post call was 1.5 points higher (95% CI 0.22 – 2.73, p=0.03) in residents who qualified for a post-call day. The academic activities compromised by post-call included clinic (33%), operative experience (17%), and research and study time (17%). Residents did not take a post call day despite meeting requirements based on time elapsed and fatigue in 33% of calls. 

Conclusion: This was a successful pilot study evaluating the feasibility of this research project to monitor the selected variables and outcomes during resident home call. The authors identified a disproportionately high amount of non-urgent calls that residents received over the course of their call. The experiences of these residents will provide insight into the events encountered on call in a home call setting that may impede academic performance in residency training programs. The authors are optimistic that the significant results of this study will stimulate further investigations into educational reform as it relates to residency training programs in Canada.

 

18.04 The Use of Mobile Video Technology to Improve Patient Care during Call

Posted on December 22, 2014

N. Nosrati1, W. A. Wooden1, R. L. Flores1, R. Sood1, S. S. Tholpady1  1Indiana University,Plastic Surgery,INDIANAPOLIS, IN, USA

Introduction: One of the key learning opportunities in plastic surgery residency is taking call. The residents are on their own to make the initial diagnosis and plan and to effectively communicate all the data to their attending. One component is accurately reading imaging studies. The maxillofacial computed tomography imaging is among the more complex a plastic surgery resident will encounter on call. In this study, we analyzed the resident’s ability to read and process the films.

Methods: Using the plastic surgery sign out system, images were extracted from the previous 4 months. The images used were identified by the on-call resident as the crucial CT slices to make the diagnosis and plan. The corresponding computed tomography films were identified. Using a Pantech P4100 tablet, these films were video recorded. The images and films were then grouped according to resident year. Individually, each craniofacial attending was first shown the images and asked to decide on a management plan.  They were then shown the video and asked if their management changed. Changes in plans were recorded.

Results:A total of 15 films were identified, 6 in the first year independent, 2 in the second year independent, 3 in the fourth year integrated, and 4 in the second year integrated.  Image data was missing on 37 sign outs. Attending 1 changed his plan 40% of the time, attending 2 20% of the time, and attending 3 6.7% of the time for an average change of 22.2%. All attendings independently agreed on 7 operative plans.

Conclusion: As resident level progressed, selection of crucial slices of imaging improved. However, even in the more senior years there was some discordance with image selection. While CT is not the sole factor in management of craniofacial trauma, it does play a significant role. All the study participants agreed, having a full CT available improves communication and planning. In areas where information systems do not allow for easy viewing of images, the transmission of video with a full CT provides an alternate method to evaluate and change resident plans leading to improved patient care and resident education.

If feasible, especially in earlier resident years, use of computed tomography video recordings greatly enhances patient management and resident education of craniofacial trauma.
 

18.05 The Characteristics of Effective Mentorship for Female Academic Surgeons

Posted on December 22, 2014

A. Cochran1, W. B. Elder1, L. A. Neumayer2  1University Of Utah,General Surgery,Salt Lake City, UT, USA 2University Of Arizona,Tucson, AZ, USA

Introduction:  The lack of same-sex mentors and senior female role models for female academic surgeons has been postulated as a source of isolation and cited as a limitation in career development.  Inadequate mentoring also contributes disproportionately to junior female academic surgeons considering exit from academia.  The goal of this study was to describe how successful mid-career and senior female academic surgeons describe effective professional mentorship.

Methods:  A single interviewer conducted semi-structured interviews with 11 mid-career and senior female academic surgeons.  Each interviewee was asked to discuss barriers they had experienced or observed during their academic surgical career.  Participating surgeons were purposefully selected to maximize institutional, specialty, and ethnic diversity.  Grounded theory methods were used to develop a theoretical model of the mentoring needs of female academic surgeons; the use of grounded theory allows for development of a theory grounded in the unique experiences and observations of female academic surgeons.

Results: Finding appropriate invested mentorship was described as a barrier to an academic surgical career by most interviewees (6/11); this theme was explicitly expanded during the course of their interviews through discussion of how they define mentorship and how it has impacted their career development.  The theme most commonly described was the need for more than one mentor (9/11); the various participants described this need across the trajectory of their career, across disciplines to meet both clinical and scholarly needs, and even across institutions. Most interviewees also indicated a need for a mentoring committee or team if one is to succeed in academic surgery (6/11), with one surgeon stating, “Success is not in isolation.”  Seven surgeons described the key quality of a mentor as being invested in the success of the mentee without personal gain to the mentor. Almost all interviewees described the primary work of mentoring as assisting the mentee to develop a strategy to achieve their goals (10/11).  The majority of respondents recognized that while part of the work of the mentor is to insure regular engagement and interaction occurs, the mentee has a responsibility to come prepared with specific goals and issues requiring the mentor’s assistance (7/11).

Conclusion: Effective mentorship is often cited as a key to success for women in academic surgery, although no prior studies specifically delineate the characteristics of effective mentorship.  A need for multiple mentors across time and disciplines was clearly identified from both a mentor and mentee perspective.  The idea of “mentorizing” experienced individuals by actively seeking specific input was identified as an effective strategy for mentees.  Finally, effective mentors are seen as those individuals who achieve no personal gain from their role but instead derive satisfaction from the success of others.

 

18.06 Restrictive Covenants: A Survey of Residents Understanding and a Call for Increased Education

Posted on December 22, 2014

C. M. Forleiter1, A. M. Al-Ayoubi1, R. J. Chouake1, M. Barsky1, S. Rehmani1, F. Y. Bhora1  1Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital / Department Of Thoracic Surgery,New York, NY, USA

Introduction:  Several significant concerns have been raised regarding restrictive covenants (RCs) and their impact on the medical profession. The purpose of this research is to assess the understanding of the current residents and raise awareness about this important topic.

Methods:  An anonymous electronic survey was sent to all 432 residents at a tertiary hospital in New York City. The survey was comprised of 30 questions including demographics, a pre-test, educational material, and a post-test to assess trainees understanding of restrictive covenants, and their impact on physicians’ jobs, lives, and patients’ care. 

Results: There were a total of 115 responses (27% response rate) across all the major residency programs. Overall, 45% of residents were not even aware of restrictive covenants prior to this survey and 87% of residents have received no formal education in employment contracts in medical school or residency. After a short pre-test followed by educational material, the overall percentage correctly answered improved on every question asked on the post-test (see chart). 94% of residents were concerned about a geographic and/or time restriction should they change jobs and 90% thought having to relocate would affect them significantly, citing patient relationships, referral patterns, spouse’s career and children’s schooling as reasons. Over 80% of residents never discussed contract negotiations with an Attending mentor and 83% did not know physicians could bargain RCs out of their contracts. Most residents polled think restrictive covenants damage the physician-patient relationship (84%) and do not belong in a profession like medicine (71%). Lastly, almost all respondents will pay more attention to restrictive covenants when signing their next contracts (76%).

Conclusion: There is a considerable lack of awareness and discussion among medical trainees regarding restrictive covenants. Residents feel RCs have the potential to significantly affect the practice of physicians and limit patients’ access to their doctors. With just a little educational material, residents across all specialties polled were able to demonstrate understanding and almost all seemed concerned that RCs would negatively impact their lives, both personally and professionally. Further assessment from the larger medical community is warranted, with a heavy emphasis on education.
 

18.07 An Apprenticeship Rotation Teaches Chief Residents Non-technical Skills and ACGME Core Competencies

Posted on December 22, 2014

G. Kwakye1, X. Chen1, J. Havens1, J. Irani1, D. S. Smink1  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction:   Traditionally, surgical training utilized an apprenticeship-model but has more recently moved to a service-based model, with groups of residents working with groups of attending surgeons.  We developed an apprenticeship rotation to encourage more one-on-one interaction between residents and faculty. We hypothesized that the apprenticeship-model would be effective for teaching non-technical skills (NTS) and core competencies.

Methods: Surgery chief residents from two consecutive classes at a single institution identified a preceptor to work with over a dedicated one-month rotation.  Emphasis was placed on acquiring the 4 non-technical ACGME core competencies- Interpersonal Skills and Communication (ISC), Practice-based Learning and Improvement (PBLI), Professionalism (Prof), and Systems-based Practice (SBP). Participants were surveyed anonymously afterwards about their rotation.

Results:   100% (13/13) residents and 67% (8/12) faculty completed the survey.  84.6% of residents and 87.5% of faculty would recommend the rotation to others.  Both groups felt that technical skills (TS) and NTS improved.  However, there was a trend for faculty to find the rotation more useful at teaching NTS than TS (NTS: mean 4.63, median 5.0; TS: mean 3.63, median 4.0; p<0.06). Residents reported improvement in all 4 non-technical competencies, particularly PBLI, Prof, and ICS.  85% felt the skills obtained were relevant to their intended career or fellowship training.

Conclusion:  The apprenticeship-model is an effective means of teaching residents both TS and NTS essential for independent practice. Faculty and residents, however, differ on the area of greatest impact, with faculty reporting greater improvement in non-technical competencies. Consideration should be given to introducing this program into surgical curricula nation-wide and expansion to other residents.

18.08 Palliative Care Training in Surgical Oncology and Hepatobiliary Fellowship: National Fellows Survey

Posted on December 22, 2014

G. Larrieux1, J. T. Miura1, K. J. Brasel1, D. E. Weissman2, A. B. Nattinger3, T. C. Gamblin1, K. T. Turaga1, F. M. Johnston1  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Palliative Care,Milwaukee, WI, USA 3Medical College Of Wisconsin,Medicine,Milwaukee, WI, USA

Introduction: Surgical Oncologists (SO) and Hepatobiliary (HPB) Surgeons frequently care for patients with advanced disease stages who are near the end of life, yet little is known about their training, comfort and readiness in the provision of palliative care.  This study sought to assess the quality, adequacy and extent of palliative care training and readiness of SO and HPB Fellows in delivering palliative care.   

Methods: A self-administered survey was distributed to all fellows enrolled in Society of Surgical Oncology (SSO) and HPB fellowships during the 2013-2014 academic years.  The survey assessed attitudes, training, experience, and readiness of fellows in caring for patients at the end of life.  Descriptive analysis was performed and Chi-square, Student’s t-test as well as Mann-Whitney U test were used to compare mean or median values as appropriate.

Results:The response rate was 47.2%. 50.9% of fellows reported exposure to a palliative care specialty service during their fellowship. 75% of our participants observed their faculty discussing the side effects of surgery compared to 54% observation of faculty’s communication regarding end of life goals with patients (p<0.01). 40% of fellows were never observed by faculty discussing symptoms management, goals of care, or hospice referral with patients and 56.7% never received feedback on their palliative skills. Fellows consistently rated their quality of teaching and managment of surgical disease at better compared to palliative and end of life topics (Figure 1).

Conclusion:Fellows rated the quality of palliative care education as poor compared to other aspects of fellowship training, implying the need and lack of palliative care teaching.  Surgical oncology and HPB fellows and ultimately patients may benefit from increased clinical and didactic palliative care training.
 

18.09 Administrative Chief Residents – How are they chosen and does it matter?

Posted on December 22, 2014

A. Weiss1, D. Tandon1, B. Chandrasekaran1, V. Tapia1, K. C. Lee1, S. Ramamoorthy1, S. L. Blair1  1University Of California – San Diego,San Diego, CA, USA

Introduction: There is no existing literature on the process of appointing administrative chief residents (ACR) in surgical programs; nor on the disparity of minority representation in this position. This study’s purpose was to examine various residency’s processes and the demographics of the residents who have held the position.

Methods: After IRB approval was obtained from UCSD, a 20 question survey was sent to all surgical program directors and residency coordinators in the United States – to survey all residents and faculty. Survey Monkey, an online survey program, was used to question and analyze the results.  A survey was developed for use in this study.  It was piloted at our institution and revised prior to release.

Results: There were 101 survey respondents, an approximate 10% response rate. 99% of these were general surgeons and 97% had ACRs at their program.  85% were residents, 56% were male, 53% were resident level 3-5 and 3% were full professors. 50% of respondents were from a program with 20-50 residents, 65% from a program with 50% female residents, 76% with 25% ethnic minorities. 71% of respondents report that there is no clear policy on the ACR position, to the best of the respondent’s knowledge 63% believe the position is appointed. In the last 5 years, half of respondents had less than 25% female ACRs and 31% had less than 50% female ACRs. Similarly, 52% had zero minority ACRs and 40% had 25% minority ACRs. 49% believed making the call schedule was the most important responsibility of the ACR; 27% believe being respected by the residents is the most important quality and 24% believe organization to be most important. 54% of respondents believe their ACR receives a stipend, but 70% report there is no training involved. 35% of respondents report that in the last 5 years 50% of their ACRs went into academic practice, and 30% report that more than 75% went into academics.
 

Conclusion: Although most surgical programs in the country train 50% female residents, most have less than 25% female ACRs over the last 5 years. This trend is similar for ethnic minority residents. ACRs in the United States are often receiving a stipend, and are more often going into academic practice. ACR is a position that most respondents feel commands respect and carries with it potential monetary and career advantages; thus programs should keep diversity in mind in appointing ACR.
 

18.10 Novel Electromechanical Simulator for Training in Cardiopulmonary Bypass

Posted on December 22, 2014

J. Fernandez1, P. Frank1, J. Resnik2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiothoracic Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Department Of Anesthesiology And Perioperative Medicine,Los Angeles, CA, USA

Introduction:  Training of physicians and healthcare professionals in the management of cardiopulmonary bypass (CPB) poses major challenges. These include the complexity of the cardiovascular system as well as the rarity of catastrophic events. In light of these challenges, a widely available and realistic simulator for bypass is needed and is yet lacking. We aimed to design an artificial, computer-controlled CPB simulator that would generate the responses of the human body to various hemodynamic states. Further, we hoped that this CPB simulator could be coupled to the CPB machine that is typically used by cardiac perfusionists during cardiac surgery. 

Methods:  The CPB simulator was driven by computer control and feedback. LabVIEW 2013 software (National Instruments, Austin TX) was used to design a graphic user interface similar to a patient monitor. The computer also controlled a pump via a customizable pulse-width modulated waveform to simulate cardiac ejection of arbitrary strength and duration. A series of control valves were placed in the circuit to simulate the systemic vascular resistance. 

Results: A computer algorithm was able to generate normal and abnormal scenarios that commonly present in the emergency department or operating room. The CPB simulator uses an algorithm for increasing and/or reducing the cardiac output of the system based on heart rate and preload without user input. The system generated various conditions, including hypovolemic, cardiogenic and distributive shocks. The CPB simulator was able to respond to virtual administration of chronotropes, inotropes, vasoconstrictors, and vasodilators in real time. The system was successfully connected to a clinical bypass machine and initiation and weaning of bypass was performed. The simulator was found to be realistic by a cardiac surgeon and a perfusionist.  

Conclusion: We have demonstrated the feasibility of a simulator that incorporates computer algorithms, displays, and actual mechanical fluid dynamics to provide a suitable platform for cardiopulmonary bypass practice. Given its simplicity and low cost, this CBP simulator should be used in individual and team scenarios. Routine practice may potentially be lifesaving in cases of pump emergencies such as power failure and air embolism. The simulator also provides an ideal setup for team training that would include members of surgical, anesthesia, and perfusion training programs.

18.11 Low-Cost Cardiothoracic Skills Simulator for Mentored Remote Practice

Posted on December 22, 2014

A. J. Doud1, E. Roselli2, G. Loor1  1University Of Minnesota,Cadiothoracic Surgery,Minneapolis, MN, USA 2Cleveland Clinic,Cleveland, OH, USA

Introduction:  Traditional methods of passing surgical expertise from mentor to student have relied on observation and graduated repetition of core component tasks, built together gradually into a broader surgical competency. While simulation in medical training has emerged as a supplemental alternative means of polishing surgical skill, ultimately time spent in the operating room with a surgical mentor is what knits together these skills into a meaningful body of applicable knowledge. However, direct contact with a surgical mentor is limited by availability, caseload and the educational needs of other students. Ideally, surgical mentorship would focus on the critical elements of a student’s deficits, offer timely feedback for improvement, and be readily available in a student’s down-time. Here we present an early-concept system for mentored surgical practice, which may be assembled with 3D-printable and off-the-shelf components.  The system may be supported by a web-based video exchange system, which allows students to upload video of their surgical training from the home or training lab, receive critique from surgical mentors reviewing their videos remotely, and monitor their improvement over time. 

Methods:  Tasks included in the trainer are focused on cardiothoracic surgical practice.  Stations present in the trainer include coronary anastomosis, mitral valve replacement, aortic valve repair, aortic grafting and cannulating. Dimensions of obstacle and barrier pieces were modified from prototype models produced from averaged CT anatomical data for difficult cases in each sub-competency of surgical practice. Vascular simulation material was constructed from a variety of fabrics selected for realism of feel when suturing.  Attention was paid to approximating the spatial and tactile constraints of working within the mediastinum.

Results: All components of the cardiothoracic trainer were fabricated from either off-the-shelf components or 3D-printable components. These components were printed in PLA plastic using a Makerbot Replicator 2 printer. The machine was able to preserve the geometry of all components and produce a set of pieces needed for a trainer in under 10 hours of unsupervised machine time.

Conclusion: Previous prototypes of the surgical trainer required prohibitively costly large-scale fabrication methods to produce the parts needed for the trainer, which in its primary iteration obviated widespread resident use.  We took a new approach in attempting to replicate the functionality of the prior prototype, while exchanging “off-the-shelf”, or small volume 3D-printed components for more costly machined or manufactured parts. Over 50% cost reduction per unit was achievable independent of production volumes . The next round of investigation will focus on in-home use of the system by surgical residents using a novel tele-mentoring system actively under development.
 

18.12 Fabrication of High Fidelity Simulated Breast Skin: A Comparison of Three Silicone Elastomers

Posted on December 22, 2014

K. Maciolek1, A. Terry1, R. Ray1, S. Laufer1, P. Barlow1, C. Pugh1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA

Introduction:  The clinical breast examination (CBE) poses a unique teaching challenge. Students are uncomfortable and ill prepared to perform the CBE at the end of training. Simulation technology provides a readily available learning platform for training CBE skills. However, current commercial simulators have a homogenous appearance and consistency that lack realism crucial for trainees to achieve competency. The study aim was to assess the visual and tactile realism of three silicone breast skins for improvement of the skin currently used for one CBE simulator.

Methods:  Study participants (N=42) included a convenience sample of clinicians at an academic training program: nurses (N=23), medical students (N=9), pharmacy staff (N=6) and physicians (N=3). Participants performed CBEs on three breast models prepared from the same mold but using different silicone materials (Smooth-On, Inc., Easton, PA). Material A was a single layer of Soma Foma 15, material B was a single layer of EcoFlex 30, and material C was three layers, two made with Dragon Skin 10 and a middle layer containing 200% Slacker. On day one, the breast skins were filled with a hard breast positive, and on day two a soft silicone mastectomy insert (Nearly Me Technologies, LLC, Waco, TX). After performing the CBE, participants completed a survey to assess the realism of the shape, softness and elasticity of the breast and nipple (4-point Likert scale: 0 = Not at all realistic; 3= Highly realistic) and ranking the models on visual appearance, tactile characteristics and overall realism. Repeated measures ANOVA tested if the samples differed in realism. A Chi-Square was performed on the rank questions of visual, realistic feel and overall preference.

Results: All forty-two participants (90.4% female) performed CBEs on all three of the different materials. Soma Foma was rated as much more realistic than EcoFlex and Dragon skin on all measures (shape, softness and elasticity) with the exception of the shape of the nipple, p>.05 (Table 1). Soma Foma was ranked higher on visual appearance, tactile characteristics and overall realism compared to EcoFlex and Dragon skin (p<.001). These results were independent of the breast insert that was placed under the skin (p>0.05).

Conclusion: This study was successful at collecting useful discriminating information about different silicone materials used to fabricate CBE simulator skins. Overall, participants preferred the skin comprised of Soma Foma. Review of participant comments suggests that Soma Foma’s superiority may result from the idealistic youthful appearance and overall heat retention at room temperature. Further work is needed to assess the role of how psychosocial factors effect evaluations of simulator realism.
 

18.13 Commercial Video Camera Use in the Operating Room: GoPro HERO3+, Contour+2, and TASER AXON Flex

Posted on December 22, 2014

S. N. Graves1, S. Davidson1, A. Langerman2  1University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA 2University Of Chicago,Department of Surgery,Chicago, IL, USA

Introduction:
Video recording in the operating room acts as a record of operative performance, provides useful data for quality improvement, and serves as a platform for sharing surgical technique and knowledge. There are many challenges to collecting video in the operating room to include user interface, physical obstruction of field of view, and contrasting light conditions. Commercially available, off-the-shelf camera systems can facilitate surgical education and record keeping in the operating room by providing a low cost solution for high-definition point-of-view video capture.

Methods:
The GoPro HERO3+ Black Edition, Contour+2, and TASER AXON Flex cameras were field tested for suitability of use in the operating room. Each camera was tested in a clinical and non-clinical setting and evaluated for quality of video and ease of operation. Non-clinical testing consisted of app interface and camera adjustments to ensure comfort, stability, and video quality. Clinical testing consisted of recording surgical procedures, further adjustment of camera settings to compensate for the live operating room environment, and optimizing video collection workflow.

Results:
Head mounting each camera using the respective manufacturer’s head mounting devices accomplished the best point-of-view video collection. The TASER AXON Flex camera was the most comfortable camera, but camera settings could not be adjusted to achieve high quality video capture. The GoPro and Contour cameras produced the best, usable footage in terms of resolution and ability to compensate for the contrasting light environment surrounding the surgical field, with the GoPro producing the best overall footage of surgical procedures. The Contour+2 is only capable of wide-angle field of view and did not adequately capture minute procedures performed during surgical procedures. The optimal video settings for the GoPro HERO3+ Black Edition were found to be a resolution of 1080p with the Protune function enabled, field of view set to ‘narrow’, and white balance set to automatic. Optimal settings for the Contour+2 were determined to be a resolution of 1080p with high video quality, automatic white balance, and contrast, sharpness, and exposure set to 62, 3, and -4, respectively. 

Conclusion:
Commercially available off-the-shelf cameras are a viable option for video collection in the operating room. Cameras must be capable of compensating for contrasting light conditions, provide adequate data security, and be easily operated in order to ensure optimal video capture. The GoPro HERO3+ and Contour+2 cameras are technically sophisticated enough to capture high definition footage in the operating room environment, while the GoPro HERO3+ produced the highest quality video capture of the cameras tested during surgical procedures.
 

18.14 Cost-Effective Vessel Ligation Simulator Develops Transferrable Surgical Skills

Posted on December 22, 2014

Y. Hu1, I. A. Le1, R. N. Goodrich1, K. D. Brooks1, B. L. Edwards1, J. R. Gillen1, A. T. Schroen1, P. W. Smith1, S. K. Rasmussen1  1University Of Virginia,Surgery,Charlottesville, VA, USA

Introduction: Simulation training facilitates operative teaching while safeguarding patient safety. However, a cost-effective model for open vessel ligation does not exist. We hypothesized that a durable vessel ligation simulator that effectively evaluates and instructs junior trainees can be constructed and implemented for less than 100 USD.

Methods: VesselBox was designed to simulate vessel ligation using expired surgical gloves as surrogate vessels. Construction cost was 30 USD; flexible cost was 0.17 USD per ligation. Model construct validity was previously demonstrated through assessments of students, residents, and faculty. To assess model effectiveness, graduating fourth-year medical students were video-recorded while performing ligations using VesselBox. These pre-test recordings were evaluated by three blinded surgical faculty using the Objective Structured Assessments of Technical Skills global rating scale (GRS) and a task-specific checklist. Subsequently, each student was trained using VesselBox in an adaptive practice session tailored to learning speed through cumulative sum. Lastly, post-tests were performed on fresh human cadavers and assessed with blinding toward pre-test results. Inter-rater correlation was assessed by Spearman’s correlation coefficient, and changes in proficiency were measured using the signed rank sum test.

Results: Among 16 students, pre-test scores averaged 2.29 out of 5 for the GRS (interquartile range, IQR 2.01-2.5) and 4.83 out of 8 for the task-specific checklist (IQR 4.17-6.33). Pre-test inter-rater correlation for the two metrics were 0.92 (p < 0.001) and 0.67 (p = 0.025), respectively. VesselBox practice sessions averaged 21.8 min per participant (IQR 19.5 – 27.7), and consisted of between 8 and 13 ligation repetitions. Average training cost was 1.87 USD per participant. Post-tests demonstrated skill transferability and improvement, as measured by both GRS (3.23 vs 2.29, p < 0.001, Figure 1A) and checklist metrics (7.33 vs 4.83, p < 0.001, Figure 1B). Median speed improved from 128.2s to 97.5s per ligation (p = 0.001).

Conclusions: VesselBox is an innovative, cost-effective model for open vessel ligation. Ideally suited for graduating medical students and junior surgical residents, VesselBox has proven utility in both evaluative and practice settings. In the interest of patient safety, simulators for open surgical skills should be used to certify baseline proficiency in a pre-clinical setting.

18.15 Unidentified Retained Foreign Object Simulation: a training for residents on root cause analysis

Posted on December 22, 2014

N. Young1, D. Patterson1, G. A. Merica1, R. Grim1, T. Bell1, V. Ahuja1  1York Hospital,Surgery,York, PA, USA

Introduction:  Gawande et al. (2003 NEJM; Risk Factors for Retained Instruments and Sponges after Surgery) concluded that intra-operative high blood loss, unplanned change in operation, and multi-operative teams increases the risk of an unidentified retained foreign object (URFO). To this end, our community hospital’s URFO policy was revised to mandate a radiologic film in addition to counts. A simulation was created to educate trainees on systematic approaches to preventing URFO in the operating room (OR) and utilizing root cause analysis to learn from sentinel events.

Methods:  A multi-disciplinary team including residents and OR staff, designed a scenario that would simulate an emergency that is susceptible to URFO error-a laparoscopic procedure that is emergently converted to open due to trocar placement arterial injury. The scenario had massive blood loss requiring mass transfusion protocol with multiple operative teams. Purposeful environment of poor communication and team work with high noise level was created. The team joined the residents in the lecture hall who watched the proceedings via videoconference. The Patient Safety Officer (PSO) gave a report that 5 days after abdominal closure a retained sponge was found on abdominal x-ray. The group was led through a root cause analysis process by the PSO. An Event Flow Diagram was described followed by an Event Causation Diagram (Fig. 1).

Results: Using a survey, the majority of the trainees recognized URFO as the sentinel event during the simulation, 11/14 (78.6%) (p = .057). 78.6% of trainees indicated the sentinel event was due to “Failure of Crew Resource Management Performance,” and indicated “Performing Radiologic Films” could prevent or reduce the number of these events. However, 100% of the trainees indicated that team work was not an issue. Out of a maximum of 5 points, trainees rated “overall communication” a mean of 4.1. Communication from anesthesia to team had the lowest score (M=2.9), followed by surgeon to nurse (M=4.3) and nurse to surgeon (M=4.4). After the scenario, our focus was root cause analysis. 78.6% of the trainees correctly indicated that “finding the individual responsible for the mistake” was not the goal, but understanding the primary focus of the root cause analysis of this scenario was “system design.”

Conclusion: The trainees were given the opportunity to learn the concept of root cause analysis and identify factors that lead to URFO. Communication and adherence to policy and procedures is essential in the operating room to reduce sentinel events. Simulation is a methodology that needs to be explored further to develop a framework for patient safety curriculum in graduate medical education. 

18.16 Residents’ Perception of Skill Reduction during Dedicated Research Time

Posted on December 22, 2014

R. D. Ray1, P. B. Barlow1, A. D. D’Angelo1, C. M. Pugh1  1University Of Wisconsin,Department Of Surgery, School Of Medicine And Public Health,Madison, WI, USA

Introduction: Surgery residents may take years away from clinical responsibilities for dedicated research time. Evaluating the potential reduction in surgical skill and knowledge is critical to ensuring competent, independent performance at the end of training. As part of a longitudinal project, the study aim was to investigate residents’ perceptions of clinical skill reduction during dedicated research time. Our hypothesis was that residents would perceive a greater potential reduction in skill during research time for procedures they were less confident in performing prior to entering the lab.

Methods: Surgical residents (PGY 2-3) from Midwestern training programs participated in four simulated clinical procedures (Laparoscopic ventral hernia (LVH) repair, Bowel anastomosis, Subclavian central line insertion, and Urinary catheterization). Prior to performing the simulated procedures, participants rated procedures in terms of difficulty (1=Not difficult to 5=Extremely difficult) and confidence (1=Not confident to 5=Extremely confident). They also rated what reduction, if any, they believed their time in the lab would have on their ability to perform the four procedures (1=No reduction to 5=Very large reduction). Analysis of variance tested differences in ratings among surgical tasks, and Pearson correlations calculated the relationship between months spent in the lab, confidence in performing the procedures, and estimated skill reduction.

Results:Twenty-five residents (60% female) completed the four clinical simulators. Residents had completed between 0-36 months in a lab (M=9.5 months, SD=10.3). Table 1 shows the pairwise comparisons of participants’ average perceived difficulty, confidence, and skills reduction. As the number of months in the lab increased, Confidence ratings for the bowel anastomosis and urinary catheterization decreased (p<0.05). Also, aside from LVH (r=.010), residents' perceived skill reduction was significantly, negatively related to their confidence on the surgical tasks for Bowel anastomosis (r=-.489, p<.005); Central line (r=-.688, p<.001); and Urinary catheter (r=-.531, p<.005).

Conclusion:Residents who were less confident in performing the bowel anastomosis, subclavian central line insertion and urinary catheterization perceived a greater skills reduction during research time. This relationship was not true for the LVH repair, which may result from participants’ not considering themselves to have sufficient baseline skill to accurately predict any future reduction. Future work is required to understand how resident’s perception of skills decay relates to actual changes in performance during dedicated research time and confidence when re-entering clinical practice.

18.17 Approaching surgery simulation education from a patient-centric pathway

Posted on December 22, 2014

K. W. Miyasaka1, R. Aggarwal2  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 2McGill University,Department Of Surgery,Montreal, QC, Canada

Introduction: Approaches to simulation education in surgery have traditionally focused on technical skills, recreating isolated aspects of operative or procedural situations. However, clinical practice is a patient-centered continuum of care, and competence consists of a blend of both technical and non-technical skills. In order to deliver an educational experience that is realistic and relevant to clinical practice, we implemented a curriculum built around “pathways” – simulated sequences of preoperative, intraoperative, and postoperative encounters – for first-year general surgery residents.

Methods: The pathway simulation begins with residents seeing a standardized patient (SP) in clinic, performing a preoperative evaluation and consent. They proceed to an operating room containing a procedure-specific porcine or synthetic model. A confederate assistant and anesthesiologist are also present in this fully immersive operative simulation. The same SP reprises their role for the final postoperative encounter in a simulated ward or clinic setting.

Residents are observed and evaluated by attending faculty watching via video in a separate room. Evaluations utilize rating scales endorsed by the American Board of Surgery (Pre-op: CAMEO, Intra-op: OPRS, Post-op: Mini-CEX). Both faculty and the SP provide feedback to each resident at the conclusion of the pathway.

We developed a curriculum that was implemented as a series of three-day educational modules to complement these pathway simulations for four surgical divisions at our institution (biliary, foregut, colorectal, and acute care).

Results: Repeating the pathway on the first and final day of each module enabled serial assessment for efficacy of the educational intervention in addition to residents’ level of achievement. Furthermore, the modular nature of the curriculum allowed for multiple iterations, accommodating all 16 first-year surgery residents as small groups over the course of an academic year without undue disruption to clinical services.

Conclusion: Adopting a patient-centric approach to surgery simulation, we recreated a complete sequence of patient care encounters in a realistic clinical setting, encompassing a pathway of care. Relevant training as well as objective evaluation of clinical competence could be performed in a time-efficient manner. The role of a dedicated simulation program with leadership resources to provide structure and oversight to participating faculty and residents was critical in the success and sustainability of the curriculum, which is now in its second year and in the process of being deployed at a second institution.

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