Is the quality of surgical residency applicants deteriorating?

BACKGROUND: Among directors of general surgery residencies, there is a concern that the quality of medical students applying to surgical residencies is declining. METHODS: Quality of surgical applicants was assessed by several methods including subjective opinions determined by survey and by objective data including student United States Medical Licensing Examination (USMLE) scores of matched candidates. The number of applicants interviewed, total interviews granted, proportion of Alpha Omega Alpha (AOA) students, and the rank order of the candidates matched was obtained by survey. The survey included data on postgraduate year 1 (PGY-1) residents from July 1996 to July 1999. Three mailings were made to 226 US surgical residency programs. RESULTS: Data were obtained from 90 programs. Surgery program directors disagreed with a survey statement that overall quality of applicants had declined (P <0.01), but agreed with a statement that activities of medical schools to enroll graduating students into primary care had hurt recruitment (P <0.001). Objective data revealed no change in mean USMLE part I scores of PGY-1 residents over the 4 years (P = 0.265, power = 0.81). There was no change in proportion of matched residents who were AOA over time. The mean score of all new PGY-1 residents, the rank of the first matched resident, the rank of the last ranked resident, and proportion of AOA students was higher in programs with five or more categorical spots when compared with programs of at most four (P <0.001). Across all programs, there was a trend to go lower on the rank list to fill categorical positions over time (P <0.001). CONCLUSIONS: There is a perception that medical school policies act to discourage recruitment of quality medical students into general surgery programs, and surgery programs are going deeper into their rank lists to fill categorical positions. However, the average USMLE part I score of applicants to surgical residencies and proportion of AOA applicants has not decreased.

Clinical research during surgery residency: the Chattanooga approach.

PURPOSE: The nontraditional clinical research rotation at the University of Tennessee College of Medicine-Chattanooga Unit is described and its efficacy evaluated by the number of peer-reviewed publications produced. METHODS: In 1988, a mandatory year of clinical research was added to the general surgery curriculum. The year is completed in 3 4-month rotations, 1 each during the PGY-2, PGY-3, and PGY-4 years. Curriculum vitae of 31 graduates of the traditional 5-year residency were evaluated for publications produced during residency and 1 year beyond training. Comparison was made to 15 subjects; 8 were 6-year graduates and 7 were PGY-4, PGY-5, or PGY-6 residents having completed the research year. Statistical analysis used the Mann-Whitney U test for nonparametric data as well as an independent t test with significance set at 0.05. Publications were verified by a MEDLINE search. Six-year graduates also completed a questionnaire regarding their research experience. RESULTS: Graduates of the 5-year program completed an average of 0.94 publications during residency, whereas 6-year graduates completed an average of 2.67 publications (p < 0.001). Opinions varied regarding desire to pursue research and the benefit of the research year. CONCLUSIONS: Our results demonstrate that basic science research is not the only model; academic productivity can be improved with an additional year devoted to clinical research. Advantages to this nontraditional approach include decreased likelihood of decline of clinical skills and knowledge, ability to maintain long-term projects, and a physical and mental break from a demanding clinical residency.

Prostaglandin E1 administration following orthotopic liver transplantation: a randomized prospective multicenter trial.

BACKGROUND & AIMS: Prostaglandin E1 (PGE1) has been used after orthotopic liver transplantation (OLT) based on limited clinical data suggesting PGE1 infusion improves immediate hepatic allograft function. The aim of this study was to conduct a randomized double-blinded multicenter trial to evaluate the effect of PGE1 on early hepatic and renal function in patients undergoing OLT. METHODS: One hundred eighteen patients were randomized to receive either PGE1 or crystalloid placebo intravenously after allograft revascularization. Primary end points were incidence of primary allograft nonfunction (PNF) or severe renal dysfunction. RESULTS: The incidence of PNF was 6.7% (4 of 60) and 6.9% (4 of 58) in the control and PGE1 groups, respectively. PGE1 infusion was, however, associated with improved early renal function (mean peak creatinine level of 1.4 +/- 1.0 and 2.0 +/- 1.0 in patients treated with PGE1 and placebo, respectively; P < 0.001). Severe renal dysfunction occurred more frequently in the placebo group (26.7%) than in the PGE1 group (13.8%; P = 0.65). Additionally, dialysis treatments were more frequent in the placebo group (0.7 +/- 2.0 per patient) than in the PGE1 group (0.2 +/- 1.0 per patient; P = 0.10). Initial intensive care unit stay was shorter in patients treated with PGE1 (4.0 +/- 3.6 days) compared with controls (10.5 +/- 17.1 days) (P < 0.01). CONCLUSIONS: PGE1 administration after OLT resulted in improved renal function and decreased initial postoperative intensive care unit stay but did not affect the incidence of PNF.

Failure of dialysis access: revise or replace?

Providing adequate long-term dialysis access has become increasingly difficult. In order to evaluate the operative factors associated with early failure of dialysis access, 2337 operations performed in 1124 patients over an 8-year period were retrospectively reviewed. Evaluation of 1306 procedures that eventually failed and required operative revision or repair provided the basis for this study. Access failure occurred in 459 (41%) of the 1124 patients. An average of 2.8 episodes of failure (range 1-13) were observed among this group of patients, occurring after an average of 230 +/- 9 days (mean +/- ++standard error) postoperatively, with the longest interval to failure being 2529 days. The time-to-failure for revision of a preexistent arteriovenous fistula or prosthetic graft (140 +/- 9 days, n = 449) was significantly (P < 0.0001 ANOVA) shorter than for creation of an arteriovenous fistula (272 +/- 21 days, n = 336) or prosthetic graft (299 +/- 19 days, n = 372) at a new site. Procedures performed in octogenarians tended to fail earlier (178 days). Dialysis access failure tends to recur in patients with a history of previous access problems. The time-to-failure was similar for new prosthetic grafts and arteriovenous fistulas, but twice as long compared to revision of a previous access site.

Stress steroids are not required for patients receiving a renal allograft and undergoing operation.

BACKGROUND: It is commonly believed that patients receiving exogenous glucocorticoids have hypothalamic-pituitary-adrenal (HPA) axis suppression and require exogenous, supplemental, high-dose stress glucocorticoids to meet the demands of operative or other stress. Several recent reports suggest both that clinically important HPA axis suppression is extremely uncommon and that the levels of glucocorticoids required for stress are much lower than previously believed. In addition, the high doses of steroids currently used for stress prophylaxis may actually increase morbidity and mortality. STUDY DESIGN: To test the need for stress steroids, a prospective study of 52 recipients of a renal allograft who underwent 58 operative procedures was conducted. No patient received stress steroids but only baseline, immunosuppressive doses of glucocorticoids. Clinical (hypotension, myalgias, arthralgias, ileus, and fever) and laboratory (serum sodium, eosinophil count, and 24-hour urinary-free cortisol from perioperative and nonstressed time periods) data were obtained to document evidence for adrenocortical insufficiency. RESULTS: There was no clinical or laboratory evidence for adrenocortical insufficiency in any of the patients. Twenty-four hour urinary-free cortisol levels showed that all patients had endogenous adrenocortical function and, combined with clinical outcome, this function was sufficient to meet the demands of stress. CONCLUSIONS: Adrenocortical insufficiency is much less common in recipients of a renal allograft than previously thought. Supplemental exogenous stress glucocorticoids are not required to meet the demands of operative stress in these patients. While biochemical testing of HPA axis function may sometimes reveal evidence for adrenal insufficiency, these tests do not predict clinical outcome and are far too sensitive to guide therapy.

New patterns of transplant nephrectomy in the cyclosporine era.

Several significant advances in transplantation during the last decade, among them the introduction of cyclosporine, have greatly altered the management of allograft recipients. To determine the frequency and pattern of transplant nephrectomy (TN) since cyclosporine was introduced in 1984, we reviewed our results from 1968 through 1990. During the 23 year period, 766 renal transplants were performed; 280 before 1984, when cyclosporine was first introduced into routine care and 486 after that time. Of the 280 recipients undergoing transplantation before 1984, 70 underwent TN, whereas only 61 of the 486 recipients in the cyclosporine period have undergone TN (p < 0.01). Comparing the demographics of those who had TN before 1984 with those who had TN in the cyclosporine era shows similarities: the mean age at TN (32 versus 32 years), percent male (66 versus 61), percent black (51 versus 61), percent of TN operations within six months of graft insertion (80 versus 70) and percent perioperative complications (nine versus 11). During the precyclosporine era, TN was performed more frequently in patients who received allografts from cadavers versus living related donors (30 versus 8 percent, p < 0.05), but this difference was eliminated after 1983 (11 versus 13 percent, p = NS). TN was performed more frequently after secondary versus primary transplants in the early (36 versus 23 percent) and later (23 versus 11 percent) time periods (p < 0.05 only for the later time period). It is also noteworthy that the rate of TN decreased significantly for primary and secondary transplants in the later time period. For low risk white patients and higher risk black patients the rate of TN decreased in an identical manner. We conclude that since the introduction of cyclosporine, TN is performed less frequently, the frequency of TN in lower risk (primary white) and higher risk (secondary, black, cadaveric) groups has decreased and TN has been and remains a safe procedure.

Identification of phytanoyl-CoA ligase as a distinct acyl-CoA ligase in peroxisomes from cultured human skin fibroblasts.

Phytanic acid accumulates in excessive amounts in Refsum disease, a rare neurological disorder, due to a defect in its alpha-oxidation enzyme system in peroxisomes. The activation of phytanic acid to phytanoyl-CoA by phytanoyl-CoA ligase is a prerequisite for its alpha-oxidation. The studies described in this manuscript report that phytanoyl-CoA ligase in peroxisomes is an enzyme distinct from the previously reported acyl-CoA ligases.

A prospective randomized trial between Euro-Collins and University of Wisconsin solutions as the initial flush in hepatic allograft procurement.

University of Wisconsin solution is currently recognized as the best solution for long-term organ preservation. It is recommended that UW solution be used as the in situ flush prior to organ explantation. The purpose of our study was to determine if hepatic allograft function was impaired by flushing the graft in situ with Euro-Collins and later flushing the graft ex vivo with UW solution, prior to cold storage. Fifty-six donors were randomly assigned to either an EC (n = 24) or UW (n = 32) in situ flush. The livers flushed with EC in situ were later flushed with 1 L of UW on the back table and stored in UW solution. Livers flushed with UW in vivo were similarly flushed and stored in UW on the back table. Concerning the donor allograft, there was no statistical difference (P greater than 0.05) between groups in sex, race, blood type, arterial anatomy, age, prothrombin time (PT), partial thromboplastin time (PTT), total bilirubin (TBR), direct bilirubin (DBR), aspartate amino transferase (AST), or alanine amino transferase (ALT). In addition, the recipients were compared for differences in sex, race, blood type, preoperative status, number of rejections, recipient age, length of surgery, and ischemia time and patient survival. There was no significant difference between groups (P greater than 0.05). There was no significant difference in patient survival (P = 0.238). Values for TBR, AST, ALT, PT, PTT, and AP were collected immediately preoperatively and postoperatively and on postoperative days 1, 3, 7, 14, and 28. There was no difference between groups in these values (P greater than 0.05). In our study there was no difference between the groups with respect to graft performance. This would justify the use of EC as an in situ flush during solid organ procurement and flushing with UW solution on the back table with an estimated savings of $400 to $1200 per procurement.

Results after liver retransplantation in a group of 50 regrafted patients: two different concepts of elective versus emergency retransplantation.

Liver retransplantation remains the only alternative therapy for irreversible graft failure. Previous studies have demonstrated lower survival rates for liver retransplantation than for primary grafts. After reviewing our clinical experience with 55 retransplantations out of 365 liver transplants, we found that the risk and results depend on the surrounding circumstances. Elective retransplantation was shown to be as safe as the first liver transplantation, while emergency retransplantation yielded significantly higher morbidity and mortality rates.