Assessing a Structured Mental Fitness Program for Academic Acute Care Surgeons: A Pilot Study.

INTRODUCTION: There is a well-established positive correlation between improved physician wellness and patient care outcomes. Mental fitness is a component of wellness that is understudied in academic medicine. We piloted a structured mental fitness Positive Intelligence (PQ) training program for academic surgeons, hypothesizing this would be associated with improvements in PQ scores, wellness, sleep, and trainee evaluations. METHODS: This is a single-institution, prospective, mixed-methods pilot study. All active Burn/Trauma/Acute & Critical Care Surgical faculty and fellows in our division were offered the PQ program and the option to participate in this research study. The 6-wk program consists of daily exercises on a smartphone application, weekly readings, and small-group meetings with a trained mindfulness coach. Study outcomes included changes in pretraining versus post-training PQ scores, sleep hygiene, wellness, and teaching scores. A Net Promoter Score was calculated to measure user overall experience (range -100 to 100; positive scores being supportive). For secondary analysis, participants were stratified into high versus low user groups by "muscle" scores, which were calculated by program use over time. A postintervention focus group was also held to evaluate perceptions of wellness and experience with the PQ program. RESULTS: Data were analyzed for 15 participants who provided consent. The participants were primarily White (73.3%), Assistant Professors (66.7%) with Surgical Critical Care fellowship training (86.7%), and a slight female predominance (53.3%). Comparison of scores pretraining versus post-training demonstrated statistically significant increases in PQ (59 versus 65, P = 0.004), but no significant differences for sleep (24.0 versus 29.0, P = 0.33) or well-being (89.0 versus 94.0, P = 0.10). Additionally, there was no significant difference in teaching evaluations for both residents (9.1 versus 9.3, P = 0.33) and medical students (8.3 versus 8.5, P = 0.77). High versus low user groups were defined by the median muscle score (166 [Interquartile range 95.5-298.5]). High users demonstrated a statistically higher proportion of ongoing usage (75% versus 14%, P < 0.05). The final Net Promoter Score score was 25, which demonstrates program support within this group. Focus group content analysis established eight major categories: current approaches to wellness, preknowledge, reasons for participation, expected gains, program strengths, suggestions for improvement, recommendations for approaches, and sustainability. CONCLUSIONS: Our pilot study highlighted certain benefits of a structured mental fitness program for academic acute care surgeons. Our mixed-methods data demonstrate significant improvement in PQ scores, ongoing usage in high user participants, as well as interpersonal benefits such as improved connectedness and creation of a shared language within participants. Future work should evaluate this program on a higher-powered scale, with a focus on intentionality in wellness efforts, increased exposure to mental fitness, and recruitment of trainees and other health-care providers, as well as identifying the potential implications for patient outcomes.

GPRC5C regulates the composition of cilia in the olfactory system.

BACKGROUND: Olfactory sensory neurons detect odourants via multiple long cilia that protrude from their dendritic endings. The G protein-coupled receptor GPRC5C was identified as part of the olfactory ciliary membrane proteome, but its function and localization is unknown. RESULTS: High-resolution confocal and electron microscopy revealed that GPRC5C is located at the base of sensory cilia in olfactory neurons, but not in primary cilia of immature neurons or stem cells. Additionally, GPRC5C localization in sensory cilia parallels cilia formation and follows the formation of the basal body. In closer examination, GPRC5C was found in the ciliary transition zone. GPRC5C deficiency altered the structure of sensory cilia and increased ciliary layer thickness. However, primary cilia were unaffected. Olfactory sensory neurons from Gprc5c-deficient mice exhibited altered localization of olfactory signalling cascade proteins, and of ciliary phosphatidylinositol-4,5-bisphosphat. Sensory neurons also exhibited increased neuronal activity as well as altered mitochondrial morphology, and knockout mice had an improved ability to detect food pellets based on smell. CONCLUSIONS: Our study shows that GPRC5C regulates olfactory cilia composition and length, thereby controlling odour perception.

Defining the Duty Hour for Surgical Trainees.

OBJECTIVE: Being mindful of duty hours has become an integral part of surgical training. Violations can lead to disciplinary action by the American Council for Graduate Medical Education (ACGME), including probation or even withdrawal of accreditation. It is therefore crucial to ensure these hours are accurately reported. However, as these are often self-reported by the resident, what counts as a duty hour is at the discretion of the reporter. The goal of this study is to identify what trainees and faculty include in their definitions of a duty hour. We hypothesized that there would be discrepancies in faculty versus trainee definitions of the duty hour, and that there remains an unclear understanding of which nonclinical activities contribute to surgical trainee duty hours. DESIGN: An anonymous, voluntary survey was conducted at a single institution. The survey contained 14 scenarios, and participants answered either "yes" or "no" as to if they believed the scenario should be counted within duty hour reporting. Analysis of the results included evaluating overall responses to determine which scenarios were more controversial, as well as chi square analysis comparing trainee (residents and fellows) versus faculty responses to each scenario. SETTING: This survey was performed within the Department of Surgery at the University of Texas Southwestern Medical Center, a large academic institution in Dallas, TX. PARTICIPANTS: There were 91 total faculty and trainee responses to the voluntary survey within the General Surgery Department and associated subspecialties, including 50 residents (54.9%), 4 clinical fellows (4.4%) and 37 faculty (40.7%). RESULTS: When analyzing total responses, the most controversial scenarios were taking a short period of home call (50.6% of all respondents included this as a duty hour), making a presentation for resident education (48.4%), making a presentation related to patient care (57.1%), and making a monthly call schedule (44.0%). The least controversial topic was transit to and from work (91.2% of all respondents did not include this as a duty hour). Additionally, there were statistically significant differences between trainee and faculty perceptions when it came to attending departmental curricula (96.2% trainees included as a duty hour v 81.6% faculty, p =0.02), participating in nonmandatory journal club (5.7% trainees v 23.7% faculty, p =0.01), and attending mentorship meetings (30.2% trainees v 52.6% faculty, p =0.03). CONCLUSIONS: There is no consensus as to what nonclinical activities formally count towards a duty hour. There are also significant differences identified between faculty and trainee definitions, which could have implications for duty hour reporting and ACGME violations. Further research is required to obtain a clearer picture of the surgical opinion on defining the duty hour, and hopefully this will reduce duty hour violations and better optimize surgical trainee education.

Age is associated with increased morbidity after laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy is one of the most common emergency general surgery procedures in the United States. Little is known about its postoperative outcomes for older adults because appendicitis typically occurs in younger patients. The purpose of this study was to examine the association between age and postoperative complications after appendectomy. We hypothesized that age would have a significant and nonlinear association with morbidity. METHODS: We conducted a retrospective cohort study of individuals whose laparoscopic appendectomies were recorded in the Veterans Affairs (VA) Surgical Quality Improvement Program (from 2000-2018; n = 14,619) and National Surgical Quality Improvement Program (2005-2019; n = 349,909) databases. The primary outcome was 30-day morbidity. We used logistic regression with fractional polynomials to model nonlinear relationships between age and outcomes. RESULTS: The median age (interquartile range) of the nonveteran cohort was 36 years (26-51; 8.4% of patients were 65 or older) versus 51 years among veterans (35-63; 21% were 65 or older). For veterans and nonveterans, there was a significant and nonlinear relationship between age and risk of complications. In the nonveteran cohort, the predicted probability (with 95% confidence interval) of postoperative complications was 9.8% (9.7-10.1) at age 65, 11.9% (11.7-12.3) at age 75, and 14.5% (14.1-14.9) at age 85. Among veterans, the risk was 7.5% (6.9-8.1) at age 65, 8.3% (7.6-9.1) at age 75, and 9.1% (8.1-10.1) at age 85. CONCLUSION: For both veterans and nonveterans, older age was associated with a significantly increased risk of postoperative complications. Notably, morbidity within the VA was lower for older adults than in non-VA hospitals.

Locked out of livelihoods: impact of COVID-19 on single women farmers in Maharashtra, India.

This article examines the impact of COVID-19 on the livelihoods of widows and other single women farmers from the most backward districts of Maharashtra, a state in western India. COVID-19 led to food insecurity, loss of farm incomes, decline in employment opportunities and increased debt traps for single women farmers. The paper highlights how agrarian distress and pre-existing inequalities of class, caste and gender in access to food, incomes, credit, land, markets, and decision making, were exacerbated during the pandemic, further impoverishing these women farmers. To trace these effects, the paper draws on two types of evidence gathered in Maharashtra by MAKAAM, an informal all-India women farmer's forum: observations during multiple rounds of interactions with over a hundred women farmers during the COVID-support work of providing ration and seeds undertaken by MAKAAM during India's national lockdown in 2020, and a subsequent large-scale survey covering about a thousand women. The paper also focuses on the inadequacy of state response, both in terms of providing relief and in its ability to partner with women's collectives and grassroots organisations for better outcomes. The article makes a case for strengthening social security measures for women farmers and enhancing their access to productive resources, agricultural programmes and decision-making spaces in relevant institutions.

Resuscitative endovascular balloon occlusion of the aorta: simulation improves performance but may require interval training to prevent skill degradation.

PURPOSE: Surgical trainees are exposed to less procedures with increasing need for simulation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become increasingly implemented for hemorrhage control, yet most courses are catered to faculty level with little data on trainees. We propose that routine training in this critical procedure will improve trainee performance over time. METHODS: This is a prospective, observational study at a level I trauma center involving a monthly trauma procedural program. Early in the month, trainees received hands-on REBOA training; at the end, trainees underwent standardized, class-based evaluation on a perfused trainer. Score percentages were recorded (0-100%). Endpoints included early, mid and late performance (2-12 months). Paired T-test and Pearson's coefficient were used to evaluate differences and strength of association between time between training and performance. RESULTS: 25 trainees participated with 5 and 11 repeat learners in the PGY-2 and PGY-3 classes, respectively. Median early performance score was 62.5% (IQR 56-81) for PGY-2s and 91.6% (IQR 75-100) in PGY-3s. Pearson's coefficient between time between and training and score demonstrated a weak correlation in the PGY-2s (r2 = - 0.13), but was more pronounced in the PGY-3s (r2 = - 0.44) with an inflection point at 5 months. CONCLUSIONS: Routine REBOA training in trainees is associated with improvement in performance within a short period of time. Skill degradation was most pronounced in trainees who did not receive training for more than 5 months. Trainees can be successfully trained in REBOA; however, this should be done at shorter intervals to prevent skill degradation.

When All Else Fails: A Rare Case of Postoperative Toxic Shock Syndrome Arising from Surgical Site Infection after Decompressive Neurectomy Successfully Treated with Angiotensin-2.

Toxic shock syndrome is a serious complication of Streptococcus pyogenes or Staphylococcus aureus infections associated with very high morbidity and mortality. Postoperative toxic shock syndrome is an extremely rare phenomenon which manifests as fevers, diffuse rash, septic shock, and death. We present the first reported case of toxic shock syndrome associated with a surgical site infection from a decompressive neurectomy for refractory migraines in a 41-year-old female as well as the first use of angiotensin-2 vasopressor therapy to treat persistent septic shock from toxic shock syndrome refractory to conventional therapies.

Bone Sparing Effects of Bisphosphonates in Cyclosporine-induced Alveolar Bone Loss: An Animal Study.

Various pharmacological agents are known to create an imbalance in the normal physiology of bone remodeling. Cyclosporine-A (Cs-A) is one of the drugs that is widely used in transplantation and has its main side effect as gingival hyperplasia and alveolar bone loss by their action on the inflammatory mediators. Bisphosphonates are a new class of drugs that inhibit bone resorption by decreasing the osteoclast activity and number. The aim of this study was to evaluate the effect of concomitant administration of alendronate on Cs-A-induced alveolar bone loss in a rat model.

Human Acellular Dermal Matrix Is a Viable Alternative to Autologous Skin Graft in Patients with Cutaneous Malignancy.

Skin substitutes have shown success in complex wound reconstruction. We evaluate the use of a human acellular dermal matrix (ADM) as a viable alternative to autologous skin grafting for defects secondary to skin cancer excision. An institutional review board-approved, retrospective review of ADM-reconstructed defects secondary to skin cancer excision between 2012 and 2018 was conducted. ADM was indicated in patients with preclusive factors for general anesthesia, protracted procedure time, reluctance for additional donor site wound, and personal choice. We reviewed defect characteristics, healing time, postoperative outcomes, and patient demographics. The 228 participants (151 males, 77 females) had a median age of 72 years (range, 29-95 years), with melanoma diagnosed in 113 (49.6%), squamous cell carcinoma in 61 (26.8%), and basal cell carcinoma in 28 (12.2%) patients. The median interval to complete epidermal coverage was 42 days, with graft failure evident in six patients (2.6%). ADM is a viable, low-morbid alternative for reconstruction of defects secondary to skin cancer excision, with no donor site morbidity. With exception to complete healing time, outcomes are similar to those of autologous grafting.

The evaluation of a sanitation intervention on sanitation-related emotional and psychological well-being among women and girls in Bihar

Public health externalities from unhygienic sanitation remain a significant development challenge, even in areas where hygienic latrines are accessible or affordable. Our partner, Sanergy has created a network of hygienic latrines in Nairobi. However, as with many other technical solutions to a range of development problems, widespread adoption of this "clean toilet" option has been a challenge. Barriers such as distance, cost, long queues, or lack of understanding of health risks may preclude individuals from choosing the sanitation option that may be better from a public health point of view. We also hypothesize that behaviors like open defecation may persist because they represent ingrained habits that are difficult to change. Inspired by findings from psychology and neuroscience, we propose field experiments that are designed to instill a revised habit of community toilet use among the slum population of Nairobi. Habit loops have been successfully created by private sector firms to increase demand for many household products and behaviors such as brushing regularly with Pepsodent toothpaste, or spraying Febreze air freshener. We propose to create such a loop for Sanergy toilets using a combination of economic incentives and a marketing campaign that is attentive to psychological cues and rewards. The experiments are designed to separate habit formation from other closely related models of risk aversion and learning.

Evolving Trends and Influencing Factors in Mastectomy Decisions.

It is known that survival is unaffected by the choice of surgical management for breast cancer (BC) patients. Despite this fact, recent literature reveals that the number of bilateral mastectomies (BMs) in the United States is increasing. In an effort to elucidate potential factors influencing this trend, we investigated socioeconomic and clinicopathologic characteristics of our patient cohort that could have affected a patient's decision between unilateral mastectomy (UM) versus BM. Five-hundred-eight patients with unilateral BC who underwent mastectomy between 2000 and 2009 were analyzed: 397-UM; 111-BM. Influence of patient's age, insurance status, residence (rural versus urban), subsequent reconstruction, marital status, smoking history, family cancer history, cancer stage and grade on the BM versus UM patient's decision were analyzed using independent sample t tests, χ2 and logistic regression analysis. BM was more likely to be chosen by younger (<50 years) patients (P < 0.001); patients with private insurance [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.4-3.5]; residence in urban settings (OR = 5.09, 95% CI = 2.5-10.4); and plans for subsequent reconstruction (OR = 2.31, 95% CI = 1.4-3.8). Marital status, smoking history, family cancer history, BC stage and grade did not significantly impact patient's choice of BM versus UM. We found that patients with unilateral BC who are younger (<50 year) have private insurance, reside in urban settings, or plan for subsequent reconstruction are more likely to undergo BM for unilateral BC. Genetic specific data were not evaluated for this patient cohort, and will be the subject of future analysis.

Synthesis, molecular docking and evaluation of antifungal activity of Ni(II), Co(II) and Cu(II) complexes of porphyrin core macromolecular ligand.

Porphyrin core dendrimeric ligand (L) was synthesized by Rothemund synthetic route in which p-hydroxy benzaldehyde and pyrrole were fused together. The prepared ligand was complexed with Ni(II), Cu(II) and Co(II) ions, separately. Both the ligand and its complexes were characterized by elemental analysis and spectroscopic studies (FT-IR, UV-Vis, (1)HNMR). Square planar geometries were proposed for Cu(II), Ni(II) and Co(II) ions in cobalt, Nickel and copper complexes, respectively on the basis of UV-Vis spectroscopic data. The ligand and its complex were screened on Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei by determining MICs and inhibition zones. The activity of the ligand and its complexes was found to be in the order: CuL ˃ CoL ≈ NiL ˃ L. Detection of DNA damage at the level of the individual eukaryotic cell was observed by commet assay. Molecular docking technique was used to understand the ligand-DNA interactions. From docking experiment, we conclude that copper complex interacts more strongly than rest two.