Risks and Rewards of Advanced Practice Providers in Cardiothoracic Surgery Training: National Survey

Background Changes in healthcare have led to increasing utilization of Advanced Practice Providers (APPs), but their role in Cardiothoracic Surgery (CTS) education remains undefined. This study aimed to analyze the extent of APP utilization on the CTS team, their role within the hierarchy of clinical care, and the impact of PEs on CTS training from the resident perspective. Methods CTS residents’ responses to the 2017 Thoracic Surgery Residents Association (TSRA)/Thoracic Surgery Directors Association (TSDA) In-Service Training Examination (ITE) survey regarding the role of APPs in specific clinical scenarios, and perception of APP contribution to residents’ educational environment were analyzed. Statistical analysis of categorical variables was performed in SPSS using a Fisher’s exact test and Pearson Chi-Square with statistical significance set at p<0.05. Results Response rate was 82.1% (280/341). The median number of employed APPs was 16-20 and 50.4% (n=141) reported 11-25 PEs at their institution. The median forAPPs in the operating room, floor, and intensive care unit was 3, 3, and 2 respectively. Overall impression of APPs was positive in 87.5% (n=245) of respondents, with 47.7% (n=133) being “very positive” and 40.1% being “positive” (n=112). In general, residents reported greater resident involvement in post-operative issues and operative consults and greater APP involvement in floor issues. 72.5% of residents had not missed a surgical opportunity due to APPs while, 9.6% missed an opportunity due to a APP despite being at an appropriate level of training. Of those that reported missed opportunities, 44% were I-6 residents. There were no significant differences in APPs’ operative role based on resident seniority. Conclusions The overall impression of APPs among CTS residents is favorable, and they more commonly are involved assisting on the floor or the operating room. Occasionally, residents report missing a surgical opportunity due to APPs. There is further opportunity to optimize and standardize their role within programs, in order to improve clinical outcomes and enhance the CTS educational experience for residents

Current Status of Endovascular Training for Cardiothoracic Surgery Residents in the United States

Background Endovascular interventions for cardiovascular pathology are becoming increasingly relevant to cardiothoracic surgery. This study assessed the perceived prevalence and efficacy of endovascular skills training and identified differences among training paradigms. Methods Trainee responses to questions in the 2016 In-Service Training Examination survey regarding endovascular training were analyzed based on the four different cardiothoracic surgery training pathways: traditional 2- and 3-year thoracic, integrated 6-year, and combined 4+3 general and thoracic residency programs. Results The duration of endovascular training was substantially different among programs, at a median of 17 weeks for integrated 6-year, 8.5 weeks for 3-year, 6 weeks for 4+3, and 4 weeks for 2-year residency (p < 0.0001). After adjusting for year of training and program type, the duration of endovascular rotations was significantly associated with self-assessed comfort with catheter-based skills (p < 0.0001). Eighty-two percent of residents rotated with trainees from other specialties, and 58% experienced competition for cases. Residents reported greater exposure to transcatheter aortic valve replacement than to thoracic endovascular aortic repair, cardiac catheterization, percutaneous closure of atrial septal defect, and transcatheter mitral valve surgery (p < 0.0001). A significant proportion of responders reported feeling uncomfortable performing key steps of transcatheter aortic valve replacement (52%) or thoracic endovascular aortic repair (49%). Conclusions Considerable heterogeneity exists in endovascular training among cardiothoracic surgery training pathways, with a significant number of residents having minimal to no exposure to these emerging techniques. These findings highlight the need for a standardized curriculum to improve endovascular exposure and training

A nonalcoholic fatty liver disease cirrhosis model in gerbil:the dynamic relationship between hepatic lipid metabolism and cirrhosis

Nonalcoholic fatty liver disease (NAFLD) usually takes decades to develop into cirrhosis, which limits the longitudinal study of NAFLD. This work aims at developing a NAFLD-caused cirrhosis model in gerbil and examining the dynamic relationship between hepatic lipid metabolism and cirrhosis. We fed gerbil a high-fat and high-cholesterol diet (HFHCD) for 24 weeks, and recorded the gerbil's phenotype at 3, 6, 9, 12, 15, 18, 21, 24 weeks. The model's pathological process, lipid metabolism, oxidative stress, liver collagen deposition and presence of relevant cytokines were tested and evaluated during the full-time frame of disease onset. The gerbil model can induce nonalcoholic steatohepatitis (NASH) within 9 weeks, and can develop cirrhosis after 21 weeks induction. The model's lipids metabolism disorder is accompanied with the liver damage development. During the NAFLD progression, triglycerides (TG) and free fatty acids (FFA) have presented distinct rise and fall tendency, and the turning points are at the fibrosis stage. Besides that, the ratios of total cholesterol (CHO) to high-density lipoprotein cholesterol (HDL-C) exhibited constant growth tendency, and have a good linear relationship with hepatic stellate cells (HSC) (R-2 = 0.802, P <0.001). The gerbil NAFLD cirrhosis model has been developed and possesses positive correlation between lipids metabolism and cirrhosis. The compelling rise and fall tendency of TG and FFA indicated that the fibrosis progression can lead to impairment in lipoprotein synthesis and engender decreased TG level. CHO/HDL-C ratios can imply the fibrosis progress and be used as a blood indicator for disease prediction and prevention

Preoperative Prediction of Lymph Node Metastasis in Colorectal Cancer with Deep Learning

Objective. To develop an artificial intelligence method predicting lymph node metastasis (LNM) for patients with colorectal cancer (CRC). Impact Statement. A novel interpretable multimodal AI-based method to predict LNM for CRC patients by integrating information of pathological images and serum tumor-specific biomarkers. Introduction. Preoperative diagnosis of LNM is essential in treatment planning for CRC patients. Existing radiology imaging and genomic tests approaches are either unreliable or too costly. Methods. A total of 1338 patients were recruited, where 1128 patients from one centre were included as the discovery cohort and 210 patients from other two centres were involved as the external validation cohort. We developed a Multimodal Multiple Instance Learning (MMIL) model to learn latent features from pathological images and then jointly integrated the clinical biomarker features for predicting LNM status. The heatmaps of the obtained MMIL model were generated for model interpretation. Results. The MMIL model outperformed preoperative radiology-imaging diagnosis and yielded high area under the curve (AUCs) of 0.926, 0.878, 0.809, and 0.857 for patients with stage T1, T2, T3, and T4 CRC, on the discovery cohort. On the external cohort, it obtained AUCs of 0.855, 0.832, 0.691, and 0.792, respectively (T1-T4), which indicates its prediction accuracy and potential adaptability among multiple centres. Conclusion. The MMIL model showed the potential in the early diagnosis of LNM by referring to pathological images and tumor-specific biomarkers, which is easily accessed in different institutes. We revealed the histomorphologic features determining the LNM prediction indicating the model ability to learn informative latent features

Training less-experienced faculty improves reliability of skills assessment in cardiac surgery

OBJECTIVE: Previous work has demonstrated high inter-rater reliability in the objective assessment of simulated anastomoses among experienced educators. We evaluated the inter-rater reliability of less-experienced educators and the impact of focused training with a video-embedded coronary anastomosis assessment tool. METHODS: Nine less-experienced cardiothoracic surgery faculty members from different institutions evaluated 2 videos of simulated coronary anastomoses (1 by a medical student and 1 by a resident) at the Thoracic Surgery Directors Association Boot Camp. They then underwent a 30-minute training session using an assessment tool with embedded videos to anchor rating scores for 10 components of coronary artery anastomosis. Afterward, they evaluated 2 videos of a different student and resident performing the task. Components were scored on a 1 to 5 Likert scale, yielding an average composite score. Inter-rater reliabilities of component and composite scores were assessed using intraclass correlation coefficients (ICCs) and overall pass/fail ratings with kappa. RESULTS: All components of the assessment tool exhibited improvement in reliability, with 4 (bite, needle holder use, needle angles, and hand mechanics) improving the most from poor (ICC range, 0.09-0.48) to strong (ICC range, 0.80-0.90) agreement. After training, inter-rater reliabilities for composite scores improved from moderate (ICC, 0.76) to strong (ICC, 0.90) agreement, and for overall pass/fail ratings, from poor (kappa = 0.20) to moderate (kappa = 0.78) agreement. CONCLUSIONS: Focused, video-based anchor training facilitates greater inter-rater reliability in the objective assessment of simulated coronary anastomoses. Among raters with less teaching experience, such training may be needed before objective evaluation of technical skills

Regulation of Guanylyl Cyclase-B: Characterizing the Roles of Gö6976, ATP, and P-site Inhibitors

Guanylyl cyclases (GC) play important roles in a wide range of organisms. Three transmembrane GC receptors bind natriuretic peptides with varying affinities. C-type natriuretic peptide (CNP) activates guanylyl cyclase-B (GC-B/NPR-B), which stimulates cGMP synthesis. Although the physiological effects of GC receptors have been well characterized, their regulatory mechanisms are not well understood. The inhibitory effects of the indolocarbazole, Gö6976, on GC-B activity were characterized, and data indicated that Gö6976 potently inhibits the GC activity of GC-B via a process that does not require changes in known phosphorylation sites, inactivation of all catalytic sites, or intact cell architecture. As an ATP analog, Gö6976 may inhibit GC-B by blocking the ability of ATP to activate and/or stabilize the receptor. Maximum activation of GClinked natriuretic peptide receptors in broken cell preparations requires natriuretic peptide binding to the extracellular domain and ATP binding to an unknown intracellular region. Additionally, natriuretic peptide activation of GC-B requires that the intracellular domain be phosphorylated on multiple serine and threonine residues. The dual role of ATP as an allosteric activator of GC-B and a substrate for the kinase that phosphorylates GC-B has led to confusion in the field. Enzymatic timecourse experiments conducted in crude membranes at low and high GTP concentrations support the role of ATP as an allosteric regulator of GTP. Previous studies indicated that dephosphorylation explains long-term inactivation of GCs. However, the deactivation and downregulation of a constitutively phosphorylated version of GC-B were identical to those of the wild type receptor, which indicates that these processes are phosphorylation-independent. One explanation for the time-dependent inactivation of GC-B is the binding of product compounds to the GC domain, similarly to how purine site (P-site) inhibitors inhibit adenylyl cyclase. Preliminary studies characterized the effect of 2’d3’GMP and PPi on GC-B activity in order to gain insight into the catalytic mechanisms of GC receptors