Equal but Separate: The Slow Assimilation of Osteopathic Surgery Residents Two Years After the Unified Match.

OBJECTIVES: The purpose of this study was to monitor the integration of general surgery residency programs before and after the 2020 unified match. We hypothesized that integration of osteopathic (DO) surgery residents would increase. DESIGN: We performed a retrospective cohort study of surgery residency programs between 2019 and 2021 utilizing data provided by the Association of American Medical Colleges. Program composition (2021) and changes in composition (2019-2021) were compared by program type. Multivariable logistic regression models assessed variables associated with DO presence (2021) and integration (2019-2021). SETTING: General surgery residency programs across the United States. PARTICIPANTS: Civilian surgery residencies that completed the 2019-2021 program survey. RESULTS: Out of 320 programs, DO residents were integrated at 69% (221/320), including 52% (63/122) university programs, 78% (101/129) university-affiliated programs and 83% (57/69) community programs (p < 0.01). Overall, 23 (8%) programs integrated DO residents from 2019 to 2021, and 9 (21%) ex-American Osteopathic Association programs integrated MD residents (both p < 0.01). The median number of DO residents was 1 (interquartile range, IQR 0-2) at university programs, 2 (IQR 1-7) at university-affiliated programs, and 5 (IQR 2-12) at community programs (p < 0.01). The median number of DO residents at all programs increased from 1 (IQR 0-5) to 2 (IQR 0-6) since 2019 (p < 0.01). Community (OR 2.6, p = 0.04), university-affiliated (OR 2.3, p = 0.02), and programs with DOs in 2019 (OR 19.0, p < 0.01) were associated with increased odds of DOs present in 2021, while DO faculty (OR 2.6, p = 0.02) was the only factor independently associated with integrating DOs after 2019. CONCLUSIONS: While some programs have integrated DO residents, progress is slow, median numbers of DO residents remain low, and familiarity with DOs is most associated with integration. We explore barriers to integration, and advance recommendations to eliminate potential disparities.

Developing dietary interventions as therapy for cancer.

Cancer cells acquire distinct metabolic preferences based on their tissue of origin, genetic alterations and degree of interaction with systemic hormones and metabolites. These adaptations support the increased nutrient demand required for increased growth and proliferation. Diet is the major source of nutrients for tumours, yet dietary interventions lack robust evidence and are rarely prescribed by clinicians for the treatment of cancer. Well-controlled diet studies in patients with cancer are rare, and existing studies have been limited by nonspecific enrolment criteria that inappropriately grouped together subjects with disparate tumour and host metabolic profiles. This imprecision may have masked the efficacy of the intervention for appropriate candidates. Here, we review the metabolic alterations and key vulnerabilities that occur across multiple types of cancer. We describe how these vulnerabilities could potentially be targeted using dietary therapies including energy or macronutrient restriction and intermittent fasting regimens. We also discuss recent trials that highlight how dietary strategies may be combined with pharmacological therapies to treat some cancers, potentially ushering a path towards precision nutrition for cancer.

On the Eve of Integration: Community and Affiliated Residency Programs Pave the Way Towards the Assimilation of Osteopathic Surgery Residents.

OBJECTIVE: The 2020 match integrated former osteopathic and allopathic residency programs under single Graduate Medical Education accreditation. We describe the composition of general surgery residency programs prior to the 2020 integration and provide a baseline to monitor future progress. DESIGN: Retrospective, cross-sectional data provided by the Association of American Medical Colleges for the 2018 academic year were analyzed. Descriptive analyses were used to summarize the characteristics of residents by program type and program location. Logistic regression was used to estimate factors associated with the presence of osteopathic (DO) residents. An alpha of 0.05 defined statistical significance. SETTING: Data were collected and analyzed at a United States osteopathic medical school. PARTICIPANTS: All civilian surgery residencies that approved the 2018 Program Survey. RESULTS: Out of 285 programs, the percentages with at least one DO resident were significantly different among university (44.0%), university-affiliated (62.7%) and community (78.4%) programs (p < 0.001). DO residents made up 41.4% of community residents, 13.3% of university-affiliated residents, and 2.8% of university residents (p < 0.001). A significant regional difference was observed, as DO residents made up 16.9% of residents in the central region, compared to 10.4% in the northeast, 7.0% in the south and 8.9% in the west (p = 0.004). The logistic regression analysis found that the presence of DO residents at a program was significantly related to the type of program (Affiliated vs University OR = 3.1, 95% CI 1.5-6.5; Community vs University OR = 5.2, 95% CI 1.9-14.4) and the presence of DO faculty (OR = 2.7, 95% CI 1.6-4.8) (all p < 0.05). CONCLUSIONS: We observed significant differences in the presence of DO residents in different program types. As surgical education transitions to single accreditation, this study identifies opportunities for greater integration between osteopathic and allopathic surgery training programs.

Broad Needs Assessment of Pain Education in Graduate Medical Education.

This article describes a survey-based study of graduate medical residents and fellows in an integrated health system. The study explores pain curricula, learner perspectives about pain education, and learner knowledge, attitudes, and confidence. Results indicate that pain education in the graduate medical setting is inadequate to meet learner needs.

Treating Alpelisib-Induced Hyperglycemia with Very Low Carbohydrate Diets and Sodium-Glucose Co-Transporter 2 Inhibitors: A Case Series.

Alpelisib is a α-selective phosphatidylinositol 3-kinase (PI3K) inhibitor approved for treatment of postmenopausal women, and men, with hormone receptor positive (HR+), human epidermal growth factor receptor 2 negative (HER2-), PIK3CA-mutated, advanced breast cancer (ABC). Hyperglycemia is a common, on-target adverse effect that impairs treatment efficacy and increases the rate of treatment delays, dose reductions, and discontinuation. Currently, there are no clear guidelines on how to manage hyperglycemia due to alpelisib when metformin is not effective. In this case series, we review 3 subjects with ABC that developed hyperglycemia during alpelisib-fulvestrant therapy and were successfully managed with dietary and pharmacologic interventions. These cases provide anecdotal evidence to support the use of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and very low carbohydrate diets to minimize hyperglycemia during alpelisib therapy.

Case logging habits among general surgery residents are discordant and inconsistent.

BACKGROUND: General surgery residents log operative case experience as "first assist" (FA) or "primary surgeon" (PS). This study will evaluate their quantitative and qualitative case log practices. METHODS: Modified Delphi technique was used to create a questionnaire and distributed online to institutions via the APDS. Descriptive analyses and example operative scenarios for resident case logging habits were ascertained. RESULTS: There were 363 residents from university (60%) and non-university (40%) programs; 94% did not know the definition of primary surgeon. Over 50% stated they had been encouraged to log a case as surgeon that they did not feel was warranted. Only 4% felt the current logging system is "very accurate." Given an operative scenario, residents varied how they chose to log the case. CONCLUSION: General surgery residents do not know the current definition of PS. Case logging should be an objective measure of resident operative exposure, but may actually be more complex than previously recognized.

Multi-institutional Surgical Education Interventions: A Scoping Review.

OBJECTIVE: The aim of the study was to identify and evaluate scholarship in multi-institutional interventional surgical education trials. SUMMARY BACKGROUND DATA: Most research on interventions in surgical education occurs at individual institutions. These studies typically involve a small number of learners in a unique environment, thereby limiting their generalizability. The status of multi-institutional studies in surgical education remains unknown. METHODS: We searched the Pubmed, ERIC, PsycINFO, SCOPUS, and CINAHL databases for all English language articles published from January 1, 2000 to December 31, 2015 using the keywords "medical education," "surgical education," "multi-institutional," "multi-center," and related terms. Articles published in an English language peer-reviewed journal that described an educational intervention conducted at more than one institution and involving surgeons were included. RESULTS: Of 3511 identified articles, 53 met criteria for full-text review and inclusion in this review. The median number of institutional sites was 4, with a range of 2 to 54. The 2 most common areas of focus were technical skills (43% of studies) and clinical knowledge (32% of studies). These were also the 2 most commonly measured outcomes (technical skills 32% of studies, clinical knowledge 21% of studies). Thirteen percentage of studies measured only learner attitudes and perceptions rather than learning outcomes. CONCLUSIONS: Multi-institutional surgical education studies do not uniformly incorporate characteristics of high quality research, particularly related to study design, measurable outcomes, and assessment tools used. Coordinated support, including grant funding, that addresses the challenging nature of multi-institutional surgical education research may improve the quality of these studies.

A 15-year residency program report card: Differences between the crème of the crop and the bottom of the barrel on the American Board of Surgery examinations.

BACKGROUND: American Board of Surgery examination performance represents an important residency metric. The hypothesis is that demographic differences exist between the most and least successful programs. METHODS: This was a retrospective fifteen-year study. Data focused on program Examination Index (EI). The first and tenth decile programs were compared across demographics, using an α = 0.05. RESULTS: The first decile had a higher EI than the tenth decile (91.0% ±â€¯2 .6% vs 51.4% ±â€¯5.4% [p < 0.001]). The first decile programs were larger (p = 0.001). The first decile had more military and academic programs, with fewer community programs (p = 0.01). More first decile programs were in the West with fewer in the Northeast (p = 0.02). CONCLUSION: There are clear differences in ABS examination performance based on program size, type, and location. These results essentially perform a national needs-assessment, and may evoke a spirit of competition and collaboration.

Radioactive Iodine-Related Clonal Hematopoiesis in Thyroid Cancer Is Common and Associated With Decreased Survival.

Context: Radioactive iodine (RAI) has been epidemiologically associated with the development of hematologic malignancies. Clonal hematopoiesis (CH) is a precursor clonal state that confers increased risk of leukemia and occurs at an elevated rate in patients with thyroid cancer relative to other solid tumors. Objective: We explore if the high prevalence of CH may be a result of RAI exposure and whether CH may be a surrogate in the association between RAI and leukemia. Design: CH, CH-potential driver (CH-PD), and overall survival were evaluated in 279 patients with advanced thyroid carcinoma. Results: The prevalence of CH in patients with thyroid cancer was 37%, and that of CH-PD was 5.2%. Age was the strongest predictor of CH and CH-PD. For every year increase in age, there was a 5% and 13% increase in the odds of CH and CH-PD, respectively. RAI dose was significantly associated with CH and CH-PD, even after adjustment for age, external beam radiation therapy, and chemotherapy. For every 10 mCi increase in the dose of RAI administered, there was a 2% and 4% increase in the odds of CH and CH-PD, respectively. Patients with CH-PD previously exposed to RAI had a significantly poorer survival, even when stratified by age (heart rate = 3.75, 95% CI = 1.23 to 11.5, P = 0.02). Conclusions: RAI was associated with a high prevalence of CH, and CH is a precursor state of hematologic malignancies. The implications of this study may favor identification of CH in patients where the risks might outweigh the benefits of receiving RAI therapy for thyroid cancer.

Are the kids alright? Review books and the internet as the most common study resources for the general surgery clerkship.

BACKGROUND: To define resources deemed most important to medical students on their general surgery clerkship, we evaluated their material utilization. METHODS: A prospective study was conducted amongst third-year medical students using a 20-item survey. Descriptive statistics were performed on the demographics. Kruskal-Wallis and Mann-Whitney analyses were performed on the Likert responses (α = 0.05). RESULTS: Survey response was 69.2%. Use of review books and Internet was significantly higher compared to all other resources (p < 0.05). Wikipedia was the most used Internet source (39.1%). 56% never used textbooks. Analyses of surgery subject exam (NBME) results or intended specialty with resources used showed no statistical relationship (all p > 0.05). CONCLUSIONS: Resources used by students reflect access to high-yield material and increased Internet use. The Internet and review books were used more than the recommended textbook; NBME results were not affected. Understanding study habits and resource use will help guide curricular development and students' self-regulated learning.

Surgery residents recognized less frequently over time by medical students: A twelve year study of the Arnold P. Gold Humanism and Excellence in Teaching Award.

BACKGROUND: There is a decreasing institutional percentage of surgical resident recipients of The Arnold P. Gold Humanism and Excellence in Teaching Award over time. The hypothesis was that this trend was a national phenomenon. METHODS: This was a retrospective study from 2004 - 2015, utilizing data from the Arnold P. Gold Foundation. Multiple regression was performed using the estimated ratio of eligible surgical to non-surgical residents and the year as explanatory variables, utilizing an α = 0.05. RESULTS: The percentage of surgical award winners was lower in the second study half compared to the first half (40.2% vs. 47.2%) (p = 0.02). Multiple regression showed that when controlling for the number of eligible residents, the number of resident awardees decreased over time (p = 0.01). CONCLUSION: There is a clear national trend that surgical residents are receiving the Arnold P. Gold Humanism and Excellence in Teaching Award less over time.

The American Board of Surgery examinations: how are the Southwestern Surgical Congress programs performing compared to the rest of the United States?

BACKGROUND: Our aim was to study pass rates of the American Board of Surgery (ABS) examinations for examinees from programs in the Southwestern Surgical Congress (SWSC) compared with the rest of the United States (Non-SWSC). METHODS: A retrospective review of pass rates of ABS Qualifying Examination (QE), Certifying Examination (CE), and QE/CE index from 2005 to 2015 was conducted. RESULTS: From 2005 to 2010, SWSC outperformed Non-SWSC in QE (88% vs 85%, P < .02), CE (86% vs 82%, P < .01), and QE/CE (77% vs 72%, P < .01). From 2010 to 2015, SWSC outperformed Non-SWSC in QE (91% vs 86%, P < .01) and QE/CE (77% vs 71%, P < .01) but did not achieve statistical significance in CE (83% vs 81%, P = .09). CONCLUSIONS: SWSC programs outperformed Non-SWSC across QE and CE in the early period, but only on QE in the late period. We encourage SWSC states and regional surgical societies to evaluate performance on ABS examinations and collaborate to improve surgical training.

A Sensitivity Analysis and Opportunity Cost Evaluation of the Surgical Council on Resident Education Curriculum.

OBJECTIVE: The study purpose is to evaluate the Surgical Council on Resident Education (SCORE) Curriculum regarding American Board of Surgery Qualifying Examination (ABS QE) outcomes. The goal is to perform effect size analyses, sensitivity analyses, and sample size analyses with opportunity cost estimates required to favor the SCORE Curriculum subscription regarding ABS QE outcomes. METHODS: Published data were used to construct 2 × 2 matrices regarding ABS QE outcome (pass/fail) and SCORE subscription status (subscriber/nonsubscriber). Post hoc analyses of effect sizes and sample sizes, with opportunity cost estimates, were performed to evaluate ABS QE outcomes favoring SCORE subscription (2-tailed and 1-tailed tests) using an α = 0.05. RESULTS: The absolute risk increase of SCORE subscription on ABS QE outcome was 1.6% (number needed to treat = 63). Sensitivity analyses showed that a pass rate difference of 4.9% to 7.5% was required to favor SCORE subscription (all p < 0.05). Sample size analyses required an 8- to 18-fold increase to favor SCORE subscription to achieve statistical significance with an opportunity cost of $6.0 to $13.5 million ($30,000-$67,000/program), not adjusting for inflation. CONCLUSIONS: The number needed to treat and pass rate differences required to favor SCORE subscription are large. The opportunity costs of SCORE subscription are substantial. Residency programs with more limited resources should determine if the subscription costs are financially sound.

Autophagy levels are elevated in barrett's esophagus and promote cell survival from acid and oxidative stress.

Autophagy is a highly conserved mechanism that is activated during cellular stress. We hypothesized that autophagy may be induced by acid reflux, which causes injury, and inflammation, and therefore, contributes to the pathogenesis of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). Currently, the role of autophagy in BE and EAC is poorly studied. We quantitatively define autophagy levels in human BE cell lines, a transgenic mouse model of BE, and human BE, and EAC biopsies. Human non-dysplastic BE had the highest basal number of autophagic vesicles (AVs), while AVs were reduced in normal squamous cells and dysplastic BE cells, and nearly absent in EAC. To demonstrate a functional role for autophagy in BE pathogenesis, normal squamous (STR), non-dysplastic BE (CPA), dysplastic BE (CPD), and EAC (OE19) cell lines were exposed to an acid pulse (pH 3.5) followed by incubation in the presence or absence of chloroquine, an autophagy inhibitor. Acid exposure increased reactive oxygen species (ROS) levels in STR and CPA cells. Chloroquine alone had a small impact on intracellular ROS or cell survival. However, combination of chloroquine with the acid pulse resulted in a significant increase in ROS levels at 6 h in STR and CPA cells, and increased cell death in all cell lines. These findings establish increased numbers of AVs in human BE compared to normal squamous or EAC, and suggest that autophagy functions to improve cell survival after acid reflux injury. Autophagy may thus play a critical role in BE pathogenesis and progression. © 2015 Wiley Periodicals, Inc.

Surgical Specialty Residents More Likely to Receive the Arnold P. Gold Humanism and Excellence in Teaching Award.

OBJECTIVE: The Arnold P. Gold Humanism and Excellence in Teaching Awards are given by medical students to residents. The aim of this study is to evaluate the distribution of this award based on residency specialty. The hypothesis is that surgical residents more commonly receive this award. METHODS: This was a retrospective study from 2004 to 2013. All award recipients were obtained from the Arnold P. Gold Foundation website. The specialties of award recipients were tabulated. The number of award winners per thousand specialty residents was estimated using the Accreditation Council for Graduate Medical Education Data Resource Book, adjusting for the number of awarding schools and resident specialties. All statistics used an α = 0.05. RESULTS: There were 2489 awards given during the study period, with 52.6% in medical specialties and 47.4% in surgical specialties (p = 0.45). The specialties most commonly awarded were General Surgery (22.3%), Internal Medicine (20.9%), and Obstetrics/Gynecology (20.4%). Adjusting for the number of eligible residents, there were 59.9 awards/1000 Obstetrics/Gynecology residents, 43.1 awards/1000 General Surgery residents, and 20.2 awards/1000 Internal Medicine residents (p < 0.001). CONCLUSION: Controlling for the number of eligible residents, the Arnold P. Gold Humanism and Excellence in Teaching Awards are more commonly given to surgical specialty residents.