What aspects of letters of recommendation predict performance in medical school? Findings from one institution.

PURPOSE: To study medical students' letters of recommendation (LORs) from their applications to medical school to determine whether these predicted medical school performance, because many researchers have questioned LORs' predictive validity. METHOD: A retrospective cohort study of three consecutive graduating classes (2007-2009) at the Uniformed Services University of the Health Sciences was performed. In each class, the 27 students who had been elected into the Alpha Omega Alpha (AOA) Honor Medical Society were defined as top graduates, and the 27 students with the lowest cumulative grade point average (GPA) were designated as "bottom of the class" graduates. For each student, the first three LORs (if available) in the application packet were independently coded by two blinded investigators using a comprehensive list of 76 characteristics. Each characteristic was compared with graduation status (top or bottom of the class), and those with statistical significance related to graduation status were inserted into a logistic regression model, with undergraduate GPA and Medical College Admission Test score included as control variables. RESULTS: Four hundred thirty-seven LORs were included. Of 76 LOR characteristics, 7 were associated with graduation status (P ≤ .05), and 3 remained significant in the regression model. Being rated as "the best" among peers and having an employer or supervisor as the LOR author were associated with induction into AOA, whereas having nonpositive comments was associated with bottom of the class students. CONCLUSIONS: LORs have limited value to admission committees, as very few LOR characteristics predict how students perform during medical school.

The R.O.A.D. confirmed: ratings of specialties' lifestyles by fourth-year US medical students with a military service obligation.

BACKGROUND AND OBJECTIVES: Lifestyle factors influence medical specialty choice, but which specialties are perceived to have the best lifestyles is poorly described in scientific literature. The objective of the study was to determine the rating of specialties by lifestyle. METHODS: All fourth-year US medical students with a Department of Defense service obligation who participated in the 2008/2009 military Match were invited to participate in a survey following the Match. The survey listed 18 specialties and asked students to rate the lifestyle of each one on a 9-point scale, and the mean score was used as the rating. Students also listed their specialty choice in the Match. RESULTS: The response rate was 52%, as 418 of the 797 eligible students responded and provided a rating for at least nine of the 18 specialties. The four specialties rated highest for lifestyle (1--9, with 9 being highest) were dermatology (8.4), radiology (8.1), ophthalmology (8.0), and anesthesia (7.5). The four specialties rated lowest were orthopedics (4.0), neurosurgery (3.1), general surgery (2.6), and obstetrics-gynecology (2.5). Family medicine (5.7) was the top-rated primary care specialty, followed by pediatrics (5.3) and internal medicine (4.7). Students rated the lifestyle of their own specialty only slightly higher (range 0.02 to 1.8) than all other students. CONCLUSIONS: The R.O.A.D. specialties (radiology, ophthalmology, anesthesia, and dermatology) are the top specialties with respect to lifestyle as viewed by current students. Students perceive their own specialty's lifestyle realistically. Research determining why a specialty perceived as having a lower-rated lifestyle is acceptable to some students and not others is needed.

Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass.

BACKGROUND: Internal hernias (IHs) can complicate laparoscopic Roux-en-Y gastric bypass (LRYGB). A number of radiological investigations can be used in the diagnosis. These include plain X-rays, upper gastrointestinal (UGI) series, ultrasound, and computed tomography (CT) scanning. We present radiological findings in our series of 58 symptomatic internal hernias based on our 6-year experience (2000-2006) of 2,572 LRYGB patients. METHODS: A retrospective chart review was performed of all patients undergoing LRYGB who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. Types of radiological tests performed and their results were recorded. RESULTS: Fifty-eight symptomatic internal hernias were recorded, of which 56/58 (97%) underwent radiological investigation; 2/58 went directly to surgery. Of the 56 patients who underwent diagnostic imaging, 41 plain abdominal X-rays, 37 CT scans, 26 UGI series, and eight ultrasound scans were performed. Sixty-five percent of UGI series and 92% of CT scans had positive features diagnostic of internal hernia. Performing both CT and UGI series successfully diagnosed IH in 100% of cases. Subgroup analysis did not reveal any association between positive result of imaging test and type of internal hernia. CONCLUSION: CT scanning is the single most effective radiological investigation for diagnosing internal hernias post-LRYGB. In non-diagnostic cases, the addition of an upper GI series increases the diagnostic rate to 100%.

Laparoscopic Roux-en-Y gastric bypass and its early effect on blood pressure.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery is known to have a significant effect on obesity-related comorbidities such as hypertension curing it in some (50-70%) while improving control in others. Our aim was to observe the changes in blood pressure (BP) in a cohort of 100 patients followed prospectively for 1 year after LRYGB. METHODS: BP measurements were recorded prospectively in 100 consecutive patients preoperatively and then postoperatively at weeks 1, 5, 9, and months 6 and 12. In order to reduce bias, three BP measurements were made by the same nurse at each office visit and the mean recorded. Pre- and postoperative usage of antihypertensive medication was also noted. RESULTS: Eighty-nine women and 11 men underwent LRYGB and their BP monitored for 1 year. There was an 85% follow-up rate with mean % excess body weight loss of 60. Reductions in systolic (9 mmHg) and diastolic (7 mmHg) BP measurements were seen as early as week 1 postoperatively and maintained for the duration of the observation period (P < 0.05). Furthermore, postoperative usage of antihypertensive medication is reduced to a third of preoperative use. CONCLUSION: LRYGB is associated with an early reduction in BP and antihypertensive medication usage which is maintained at 1 year after surgery. This early impact on blood pressure occurs before any significant weight loss is achieved thereby suggesting a hormonal mechanism that may be involved for the changes observed.

Roux limb obstruction secondary to constriction at transverse mesocolon rent after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Partial small bowel obstruction can occur as a result of circumferential extrinsic compression of the Roux limb as it traverses the transverse mesocolic rent from thickened cicatrix formation in this area. The aim of this study is to examine the incidence of Roux limb compression with particular attention to the timing of presentation and associated weight loss in the setting of a university hospital in the United States. METHODS: A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass who developed symptomatic small bowel obstruction requiring operative intervention from January 1, 2000 and September 15, 2006. RESULTS: Of 2215 patients, 20 (.9%) developed symptomatic Roux limb compression. The mean time to presentation was 48 days after LRYGB. By this stage, the mean percentage of excess body weight loss was 29%. Of the 20 patients, 19 underwent an upper gastrointestinal contrast study, the results of which confirmed the diagnosis. In all cases, laparoscopic intervention was successful in freeing the constricted Roux limb by dividing the cicatrix formation between the Roux limb and mesocolic window. Switching from continuous to interrupted closure of the space between Roux limb and mesocolic window appeared to reduce the incidence of this complication (P<.05). CONCLUSION: Narrowing at the transverse mesocolon rent is an uncommon cause of small bowel obstruction after retrocolic laparoscopic Roux-en-Y gastric bypass. Unlike internal hernias, which tend to occur later in the clinical course and are associated with significant weight loss, Roux limb obstruction occurs earlier after gastric bypass and is not associated with significant weight loss. Interrupted closure of the mesocolic window might reduce the risk of Roux compression.

Bioabsorbable glycolide copolymer staple-line reinforcement decreases internal hernia rate after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Internal hernias (IHs) can occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP), perhaps because of a lack of adhesion formation at the cut edges of the mesentery and a cutting through of sutures with a decrease in fat from weight loss. In patients undergoing reoperation after LRYGBP, we observed that bioabsorbable glycolide copolymer staple-line reinforcement (SLR) placed to mitigate staple-line bleeding had evoked adhesiogenesis and tissue fusion at the mesentery edges; therefore, we investigated whether use of this material decreases post-LRYGBP IH rates. METHODS: The records of the 43 patients (3%) in whom an IH developed during a mean follow-up time of 2 years in a series of 1,704 LRYGBP procedures were reviewed retrospectively. RESULTS: The IHs were in the Peterson's space (n = 4), the enteroenterostomy (n = 17), or the transverse mesocolon (n = 22). The IH rate was significantly higher in patients who had suture closure of the mesenteric defects at LRYGBP than in those without formal closure of the defects but in whom SLR was applied to the edges of the cut mesentery (P = 0.01). The suture-closure and SLR groups had similar demographic, operative, and follow-up characteristics. When transverse mesocolic IHs were excluded from analysis, patients given SLR remained less likely to have an IH (P = 0.05). CONCLUSION: Use of bioabsorbable polymer SLR may decrease the occurrence of IHs after LRYGBP. Additional studies of the effect of mesentery closure method on IH incidence after LRYGBP are warranted.

Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically. The aim of this study was to see when internal hernias occur in relation to weight loss and time course after surgery. Furthermore, we wish to examine the impact of Roux limb positioning ante- versus retrocolic and whether switching to running versus interrupted closure of the mesenteric defects created at surgery made any difference. METHODS: A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. RESULTS: Fifty-four internal hernias occurred in 2,572 patients, an incidence of 2.1%. The site of internal hernias varied: 25 (1%), transverse mesocolon; 22 (0.8%), enteroenterostomy; 7 (0.3%), Peterson's space. The mean time to intervention for an internal hernia repair was 413 +/- 46 days and average % excess body weight loss (%EBWL) in this period was 59 +/- 3.3. Subgroup analysis demonstrates internal hernia incidence to be 2 in 357 (0.6%) in antecolic Roux versus 52 in 2,215 (2.4%) in retrocolic Roux limb (odds ratio = 4, P < 0.05). Continuous closure versus interrupted stitching of mesenteric defects does not seem to alter the incidence of internal hernias. CONCLUSION: This study demonstrates that the majority of internal hernias occur after a significant (>50%) EBWL. Furthermore, the antecolic approach is associated with a much reduced incidence of internal hernia.