PGI2 Levels Research Articles

Application of a Validated Assessment Tool to Compare Autonomy and Operative Performance Between Surgical Residency Programs.

Every residency has the responsibility to determine the competency of its residents and their readiness to practice after graduation, but few objective tools exist to assess residents. The Zwisch grading scale is a validated assessment tool for operative performance which has been incorporated into a smartphone application, called System for Improving and Measuring Procedural Learning (SIMPL). This application allows residents and attendings to evaluate a resident's performance in real time. Since its implementation there have been no studies that have compared scores across all participating general surgery programs in order to identify if varying procedure difficulty affect supervision and performance ratings amongst programs overall. The SIMPL database was queried for attending ratings for Post Graduate Year (PGY 1-5). Meaningful autonomy (MA) was defined as passive help or supervision only and satisfactory performance (SP) was defined as practice ready or exceptional. Procedures were classified as "core" or "advanced" based on the American Board of Surgery Surgical Council on Resident Education (SCORE) criteria. Work relative value units (wRVU) obtained from the Centers for Medicare & Medicaid services data were matched to procedures and categorized into 3 groups (<13.07, 13.07-22, >22) based on previous work. Proportions of advanced and high wRVU (>22) procedures were calculated for each program and PGY and matched back to each corresponding evaluation as potential proxies to resident exposure to more complex operations. All evaluations were divided into quintiles based on the corresponding program's proportion of advanced and high wRVU procedures. Data were summarized using descriptive statistics and generalized estimating equations (GEE) logistic regression models were used to assess whether program proportions of advanced or high wRVU procedures are predictive of MA or SP overall and among PGY 5 residents. Overall, proportions across programs ranged from 2.2% to 32.5% (mean 12.4%) and 2.4%-22.9% (mean 11.9%) for advanced or high wRVU procedures respectively. Across PGY levels, the mean proportion of advanced (7.6, 9.6, 13.1, 13.4, 14.2) and high wRVU (4.4, 6.5, 9.8, 15.3, 19.8) procedures increased with each step in PGY. In descriptive analyses of the entire group, lower numbers of MA and SP were noted with increasing proportions of advanced/high RVU. The relationship was similar for all core procedures and when limited to PGY 5 residents, however it was not entirely consistent and showed no association with advanced procedures. Similarly, in the models lower adjusted odds of MA and SP were noted for evaluations from programs with higher proportions of advanced or high wRVU procedures for the overall group but this was less consistent when limited to PGY 5 residents and even more variable when limited to advanced procedures (Table 1). There is wide variation in the proportion of advanced or high wRVU procedures reported at different programs. Overall MA and SP tended to be lower for programs reporting more advanced procedures overall and equivocal in programs with higher wRVU procedures. Programs with higher percentage of advanced procedures showed an increase in MA and SP when looking at performance as a PGY5 during core procedures only. The MA and SP of PGY5s performance during advanced procedures was not changed by an increase in exposure to advanced procedures. These results indicate that programs with more advanced cases may not necessarily train surgeons with the appropriate level of skill, knowledge or confidence needed to be an independant and safe surgeon.

Hp eradication decreased the expression level of PG II in patients of Hp negative with gastric intestinal metaplasia: a retrospective cross-sectional study

AimsThis study aims to assess the serum levels of pepsinogen (PG)I, PG II, and gastrin (G17) in patients with gastric intestinal metaplasia (GIM) and evaluate their correlation with demographic characteristics.MethodsA total of 247 normal controls (NC) and 240 patients diagnosed with GIM were enrolled in this study. All participants underwent a gastroscopy procedure followed by pathological examination for diagnosis confirmation. The expression level of PGI, PG II, and G 17 was detected by fluorescence immunochromatography and Hp infection was detected by 13-carbon breath test. The demographic characteristics of the subjects were obtained through questionnaires.ResultsCompared to the NC group, the GIM group showed a reduction in PG II expression level [10.71(6.40,16.89) VS 9.21(6.14,14.55), p = 0.010]. GIM patients had a higher prevalence of previous Hp eradication history (14.98% VS 23.75%, p = 0.014). The low PG II group exhibited a higher incidence rate of GIM compared to the high PG II group (54.10% VS 44.44%, p = 0 0.020). In the Hp-negative(Hp-) group, there was a decrease in both PGI and PG II expression levels when compared to the Hp-positive(Hp+) group [146.73 ± 78.53 VS 125.61 ± 68.75 and 10.19(7.27, 16.58) VS 7.36(5.62,12.53), p = 0.036 and p < 0.001]. Among patients without Hp eradication history, those with low PG II levels had a higher proportion of individuals with a history of Hp eradication than those with high PG II levels (29.31% VS 3.13%, p = 0.003). Additionally, within the subgroup that underwent Hp eradication, there was a decrease in PG II expression level compared to the subgroup without Hp eradication (6.16(5.13, 7.52) VS 8.73(5.67, 13.35), p = 0.041).ConclusionThe prevalence of GIM was significantly associated with low levels of PG II. There was a significant association between HP eradication history and the prevalence of GIM. Hp eradication history resulted in reduced expression levels of PG II in Hp- GIM patients.

Multi-omics analysis combined with network pharmacology revealed the mechanisms of rutaecarpine in chronic atrophic gastritis.

Tetradium ruticarpum (A.Juss.) T.G.Hartley is a traditional Chinese medicine with a history of thousands of years, which plays an important role in the relief of gastric pain, indigestion, vomiting and diarrhea. Rutaecarpine (RUT) is one of the major active constituents of Tetradium ruticarpum (A.Juss.) T.G.Hartley with potential therapeutic activity in chronic atrophic gastritis (CAG). However, the mechanism of RUT to improve CAG is not well understood. This study aimed to evaluate the efficacy of RUT in treating CAG and its underlying mechanism. The CAG model of SD rats was established by induction with 0.1% ammonia and 20mmol/L sodium deoxycholate solution, accompanied with irregular fasting cycle. The efficacy of RUT in treating CAG was assessed through pathological examination and serum biochemical indices including PP, IL-6, MTL, TNF-α, PG I, SS, PG II, IL-10 and GAS-17. Following this, network pharmacology, 16s rRNA sequencing, transcriptomics, and broadly targeted metabolomics were conducted to unravel the underlying mechanisms of RUT's action in CAG treatment. Ultimately, molecular docking, western blotting, and immunohistochemistry were employed to validate the critical targets and pathways involved in RUT's therapeutic approach for CAG. RUT significantly improved body weight, gastric juice pH and gastric histologic injury in CAG rats. The results of serum biochemical indices showed that RUT significantly inhibited the expression levels of SS, GAS-17, IL-6 and TNF-α, and increased the levels of MTL, PP, PGI, PGII and IL-10. In addition, RUT apparently increased the expression of mucosal barrier proteins such as ZO-1, E-cadherin and claudin-4 and occludin. Network pharmacology in combination with transcriptomics revealed that the MAPK signaling pathway was the most important pathway for RUT treatment of CAG. Further analysis suggested that by regulating linoleic acid metabolism, metabolic pathways, etc. mainly related to energy metabolism, RUT intervention effectively ameliorated gastric tissue metabolic disorders in CAG rats. The 16S rRNA gene-based microbiota analysis revealed that RUT altered the composition of the intestinal microbiota and decreased the relative abundance of unclassified_Muribaculaceae. PICRUST analysis suggested that the differential bacteria may be involved in energy metabolism pathway regulation for the improvement of CAG. A comprehensive analysis of the transcriptome and metabolome showed that the RUT improved the differential metabolites through the regulation of TGER2, CBR1 and CTPS1 targets. These findings indicated that RUT's mechanism of action in treating CAG was related to modulating the gut microbiota, influencing energy metabolism, and inhibiting the MAPK signaling pathway. This provided new insights into how RUT exerts its therapeutic effects on CAG.

General surgery resident robotic training curriculum: evaluation six years after implementation.

The surge of robotic surgery over the last decade emphasizes the need for a robotics curriculum during general surgery residency. We hypothesized that the implementation of a robotic surgery resident training curriculum would have a positive impact on the general surgery residency experience during and post-graduation. Current post-graduate year 1 through 5 residents and previously graduated residents were surveyed regarding their robotic curriculum experience during residency and post-graduation. Additionally, ACGME operative case were analyzed to determine robotic case volume and to compare two different time periods of the robotics curriculum: July 2017-June 2020 (early) and January 2022-June 2023 (late). Among current residents (n = 44), 19 (43%) responded to the survey regarding their robotic curriculum experience, and 17 (89%) were satisfied with the curriculum. Of the graduated residents (n = 33), 25 (75%) responded to the survey, of which 24 (96%) felt the curriculum prepared them for their future practice. Regarding ACGME case logs, 1,091 robotic cases were performed by current residents, compared to 352 cases between 2017 and 2020. The case averages by PGY-level significantly increased 3.1 times from the early (70.4 cases per PGY level) to the late time period (218.2 cases per PGY level) (p = 0.024). Overall, our robotics curriculum has had a positive impact on resident training. Current and graduated residents are satisfied with the curriculum; there has also been significant growth in the operative case volume. This study suggests that a robotic training curriculum has value during residency and in clinical practice.

Protective Effect of Pentoxifylline on the Development of Acute Gastric Mucosal Injury in a Model of LPS-Induced Sepsis.

Alterations in the gastric mucosal barrier, one of whose fundamental components is phosphatidylcholine (PC), may play an important role in the pathophysiology of erosive gastritis secondary to sepsis. Pentoxifylline (PTX) has been shown to reduce tissue damage in various experimental models of sepsis. The aim of this study was to investigate the effect of PTX on gastric mucosa PC synthesis, leukocyte infiltration, arachidonic acid-related metabolites, inflammation, oxidative stress, NO, CO, and somatostatin in a rat model of LPS-induced sepsis. Rats were administered LPS (10 mg/kg b.w.) intraperitoneally. After 30 min (early treatment group) or 120 min (late treatment group) of LPS administration, they were randomly divided into two groups that were intraperitoneally administered saline (5 mL/kg; LPS + Saline group) or PTX (45 mg/kg; 5 mL/kg; LPS + PTX group). Control rats received only saline instead of LPS and/or PTX. Two hours after saline or PTX administration (total of 150 or 240 min of procedure), animals were anesthetized, and then gastric lavage, gastric mucosa and plasma samples were obtained and kept frozen until determination. LPS-induced sepsis changed the gastric mucosal barrier by reducing its phospholipid content, PGI2, and somatostatin levels, as well as increasing MPO, TXB2, LTB4, PLA2, and MDA. Alterations may be mediated, at least in part, by modifications in the production of NO, CO, and cGMP content. PTX had a beneficial effect on gastric lesions secondary to sepsis by restoring PC production.

Proteomic and serological markers for diagnosing cardia gastric cancer and precursor lesions in a Chinese population

Cardia gastric cancer (CGC) is prevalent in East Asia, and noninvasive, cost-effective screening methods are needed. This study investigated the diagnostic value of serum pepsinogen (PG), gastrin-17 (G-17), Helicobacter pylori (H. pylori) antibodies, and proteomic profiling for CGC and precancerous lesions. We conducted a case-control study involving biopsy-confirmed patients with CGC (n = 60), low-grade intraepithelial neoplasia (CLGD, n = 60), high-grade intraepithelial neoplasia (CHGD, n = 64), and healthy controls (n = 120) matched for age and sex from high-incidence areas in China. Serological markers including PGI, PGII, G-17, and H. pylori were measured using ELISA and Western blot, while plasma protein markers were assessed using Olink® technology. The VSOLassoBag algorithm and nine machine learning (ML) algorithms were employed to identify crucial features and construct predictive models. Various evaluation metrics, including the area under the receiver-operating-characteristic curve (AUC), were utilized to compare predictive performance. Elevated PGII levels, decreased PGR, and H. pylori infection were significantly associated with an increased risk of CGC and precancerous lesions (P for trend < 0.05). The eXtreme Gradient Boosting (XGBoost) model performed best in discriminative ability among the 9 ML models. Following feature reduction based on predictive performance, a final explainable XGBoost model was developed, incorporating five protein biomarkers (CDHR2, ICAM4, PTPRM, CDC27, and FLT1). This model exhibited excellent performance in distinguishing individuals with CGC and precancerous lesions from healthy controls (AUC = 0.931 for CGC, 0.867 for CHGD, and 0.763 for CLGD), surpassing the traditional serological marker-based model. This study underscores the diagnostic potential of serological markers and proteomic profiling in the detection of CGC. Further validation and exploration of combined biomarker approaches are warranted to enhance early diagnosis and improve outcomes in high-risk populations.

The Gastric Connection: Serum Gastric Biomarkers, Metabolic Syndrome and Transition in Metabolic Status.

Inflammation plays a crucial role in the development of metabolic syndrome (MetS). However, the roles of pepsinogens (PGs) and gastrin, known biomarkers linked to gastric inflammation, in MetS and the transition of MetS status are unclear. This research aimed to explore the relationship between MetS, the transition of MetS status, and levels of gastric biomarkers. This large-scale cross-sectional study included 19162 participants aged 18-80 years between August 2021 and March 2024. Serum levels of the gastric biomarkers PGI, PGII, and gastrin-17 were analyzed using enzyme-linked immunosorbent assay. In addition, the relationship between transitions of MetS status based on 1032 MetS-negative participants from baseline to the second health exam after 2 years was considered. The association between MetS and the transitions of MetS status and gastric biomarkers was analyzed using logistic regression models. The prevalence of MetS in the study population was 31.4%, with higher rates in males (35.2%) than females (24.6%). Gastrin-17 levels were markedly elevated in participants with MetS, a trend observed in both genders. In the logistic regression analysis, after adjusting for confounding factors, gastrin-17 levels were strongly and positively correlated with MetS in the entire cohort and in males but not in females. Male participants with MetS had lower levels of PGI and PGII than those without MetS, whereas the opposite trend was observed in females. Logistic regression analysis indicated that PGI and PGII were not independently associated with MetS. During the follow-up of 2 years, 199 (19.28%) of the 1032 MetS-negative participants transitioned to MetS-positive status. As compared to the stable MetS-negative subjects, transition from MetS-negative to MetS-positive was associated with higher levels of gastrin-17, especially in males, but not in females. Gastrin-17 is a promising biomarker for MetS, exhibiting potential utility in monitoring the transition of MetS status and revealing gender difference.

Characterizing narrative feedback and predictors of feedback content on an entrustable professional activity (EPA) assessment tool

PurposeAlthough EPA assessment tools generally allow for narrative feedback, limited data exist defining characteristics and predictors of such feedback. We explored narrative feedback characteristics and their associations with entrustment, case-specific variables, and faculty/trainee characteristics.MethodsOur general surgery residency piloted an intraoperative Entrustable Professional Activities (EPA) assessment tool in 2022. The tool included an entrustment score, four sub-scores, and narrative feedback. Given strong intercorrelations (r = 0.45–0.69) and high reliability (α = 0.84) between sub-scores, we summed the four sub-scores into a composite score. We coded narrative feedback for valence (reinforcing vs constructive), specificity (specific vs general), appreciation (recognizing or rewarding trainee), coaching (offering a better way to do something), and evaluation (assessing against set of standards). Multivariable regression analyzed associations between feedback characteristics and entrustment score, composite score, PGY level, case difficulty, trainee/faculty gender, gender matching, faculty years in practice, faculty case volume with trainees, faculty evaluation score, and trainees’ under-represented in medicine (URiM) status.ResultsForty-six faculty completed 325 intraoperative EPA assessments for 44 trainees. Narrative feedback had high valence (82%) and specificity (80%). Comments frequently contained appreciation (89%); coaching (51%) and evaluation (38%) were less common. We found that faculty gender, trainee gender, and gender match predicted feedback characteristics. Generally, entrustment level, composite score, and PGY level correlated with feedback types (Table).ConclusionEntrustment and performance relate to the type of feedback received. Gender and gender match resulted in different types of feedback. Evaluative feedback was the least prevalent and warrants further exploration since evaluation is critical for learning.

Pharmacodynamics of Qingxin Jieyu Granules for treatment of atherosclerosis and its regulatory mechanism for lipid metabolism

To elucidate the therapeutic mechanism of Qingxin Jieyu Granule (QXJYG) against atherosclerosis (AS) based on network pharmacology. The major targets and pathways of QXJYG against AS were analyzed using network pharmacology. Rat models of AS established by high-fat feeding combined with intraperitoneal vitamin D3 injection were treated daily with normal saline, atorvastatin (13.15 mg/kg), or QXJYG at 0.99, 1.98, and 3.96 g/kg for 8 weeks (n=6). Ultrasound and HE staining were used to assess the function and pathologies of the abdominal aorta. Blood lipids and serum levels of Ang Ⅱ, ET-1, TXA2, PGI2, and ox-LDL of the rats were detected using an automatic biochemical analyzer or ELISA. The expressions of LOX-1, PPARγ, RXRα, p-P65, VCAM-1 and ICAM-1 in the abdominal aorta were detected with immunohistochemistry. The rat models of AS showed obvious abdominal aorta wall thickening, increased pulse wave velocity and pulse index, decreased inner diameter of the abdominal aorta, elevated levels of TC, LDL-C, Ang Ⅱ, ET-1 and TXA2, and lowered levels of HDL-C and PGI2. QXJYG and atorvastatin treatment of the rat models significantly alleviated histopathological changes of the abdominal aorta, decreased serum levels of TC, LDL-C, Ang Ⅱ, ET-1 and TXA2, and increased the levels of HDL-C and PGI2. Network pharmacology study suggested the therapeutic effect of QXJYG against AS was mediated by regulating lipid metabolism, PPAR and NF-κB pathways. Consistently, treatments with QXJYG were found to significantly decrease ox-LDL level and LOX-1, P-P65, VCAM-1 and ICAM-1 protein expressions while increasing PPARγ and RXRα expressions in the aorta of AS rats. QXJYG alleviates lipid metabolism disorder and improves histopathological changes of the abdominal aorta of AS rats possibly by lowering ox-LDL level, reducing LOX-1 expression, activating PPARγ and RXRα, and inhibiting P65 phosphorylation to reduce VCAM-1 and ICAM-1 expression in the aorta.

Automated task-level autonomy assessment in robotic surgery.

Surgical autonomy for trainees has remained elusive to quantify. Proportion of active control time (ACT) of a trainee during a robotic case can be used as a broad measure of autonomy. However, this metric lacks in the granular detail of quantifying at what specific steps trainees were actively participating. We aim to quantify trainee involvement during robotic-assisted hiatal hernia repair at a task-specific level. We performed a retrospective review of surgical performance data from robotic-assisted hiatal hernia repairs performed. These cases were segmented into 5 tasks by AI-assisted annotation with human review. The segmented tasks included: hiatal dissection, gastric fundus mobilization, mediastinal dissection, cruroplasty and fundoplication. Tasks were excluded if video segmentation of tasks was incorrect. During each task, ACT was recorded for resident, fellow and attending. Resident and fellow ACT per task was compared using the Mann-Whitney U test. Residents had the highest %ACT in the hiatal dissection (53%), gastric fundus mobilization (84%) and fundoplication (57%) tasks. Fellows had greater than 80% ACT in all 5 tasks, with the highest %ACT in the gastric fundus mobilization (100%) and hiatal dissection (88%). There was a significant difference between resident and fellow ACT during mediastinal dissection and cruroplasty. This study demonstrates how objective performance metrics and automated case segmentation can quantify trainee participation at a task-specific level. By utilizing data afforded by a robotic surgery platform, we are able to provide an objective and automated form of assessment with minimal impact on the workflow of attendings and residents. Our findings can serve to inform residents on what steps they can expect to be involved in during the procedure, appropriate to their PGY level. With this task-level data, we can provide a roadmap for trainee progression to achieve full surgical autonomy.

Yangyin Huowei mixture alleviates chronic atrophic gastritis by inhibiting the IL-10/JAK1/STAT3 pathway.

The Chinese medicine Yangyin Huowei mixture (YYHWM) exhibits good clinical efficacy in the treatment of chronic atrophic gastritis (CAG), but the mechanisms underlying its activity remain unclear. To investigate the therapeutic effects of YYHWM and its underlying mechanisms in a CAG rat model. Sprague-Dawley rats were allocated into control, model, vitacoenzyme, and low, medium, and high-dose YYHWM groups. CAG was induced in rats using N-methyl-N'-nitro-N-nitrosoguanidine, ranitidine hydrochloride, hunger and satiety perturbation, and ethanol gavage. Following an 8-wk intervention period, stomach samples were taken, stained, and examined for histopathological changes. ELISA was utilized to quantify serum levels of PG-I, PG-II, G-17, IL-1β, IL-6, and TNF-α. Western blot analysis was performed to evaluate protein expression of IL-10, JAK1, and STAT3. The model group showed gastric mucosal layer disruption and inflammatory cell infiltration. Compared with the blank control group, serum levels of PGI, PGII, and G-17 in the model group were significantly reduced (82.41 ± 3.53 vs 38.52 ± 1.71, 23.06 ± 0.96 vs 11.06 ± 0.70, and 493.09 ± 12.17 vs 225.52 ± 17.44, P < 0.01 for all), whereas those of IL-1β, IL-6, and TNF-α were significantly increased (30.15 ± 3.07 vs 80.98 ± 4.47, 69.05 ± 12.72 vs 110.85 ± 6.68, and 209.24 ± 11.62 vs 313.37 ± 36.77, P < 0.01 for all), and the protein levels of IL-10, JAK1, and STAT3 were higher in gastric mucosal tissues (0.47 ± 0.10 vs 1.11 ± 0.09, 0.49 ± 0.05 vs 0.99 ± 0.07, and 0.24 ± 0.05 vs 1.04 ± 0.14, P < 0.01 for all). Compared with the model group, high-dose YYHWM treatment significantly improved the gastric mucosal tissue damage, increased the levels of PGI, PGII, and G-17 (38.52 ± 1.71 vs 50.41 ± 3.53, 11.06 ± 0.70 vs 15.33 ± 1.24, and 225.52 ± 17.44 vs 329.22 ± 29.11, P < 0.01 for all), decreased the levels of IL-1β, IL-6, and TNF-α (80.98 ± 4.47 vs 61.56 ± 4.02, 110.85 ± 6.68 vs 89.20 ± 8.48, and 313.37 ± 36.77 vs 267.30 ± 9.31, P < 0.01 for all), and evidently decreased the protein levels of IL-10 and STAT3 in gastric mucosal tissues (1.11 ± 0.09 vs 0.19 ± 0.07 and 1.04 ± 0.14 vs 0.55 ± 0.09, P < 0.01 for both). YYHWM reduces the release of inflammatory factors by inhibiting the IL-10/JAK1/STAT3 pathway, alleviating gastric mucosal damage, and enhancing gastric secretory function, thereby ameliorating CAG development and cancer transformation.

Reference Ranges and Comparison of Pepsinogen by Chemiluminescence Immunoassay and Enzyme-Linked Immunosorbent Assay in Chinese Population.

Serum pepsinogen (PG) is a good indicator of atrophic changes in the gastric mucosa. Gastric mucosal atrophy is a high-risk factor for gastric cancer. Serological testing for PG combined with endoscopy can help to improve gastric cancer screening. In this study, we established the reference ranges of serum PG-I, PG-II, and the PG-I/II ratio (PGR) in the Chinese population by chemiluminescence immunoassay (CLIA) and enzyme-linked immunosorbent assay (ELISA). Besides, in the real world, doctors are often confused by the results of different testing platforms. Thus, a comparison of methods CLIA and ELISA was performed. 2904 individuals were enrolled from six regions in China as part of the Chinese Adult Digestive Diseases Surveillance (2016) program. The individuals completed questionnaires and volunteered to undergo examinations, including gastroscopy, urea breath test, abdominal ultrasound examination and routine serologic tests. Serum was collected to measure PGs (including PG-I, PG-II and PGR) by CLIA and ELISA. Participants who were found obvious abnormalities or absent from the examinations were excluded. Ultimately, 747 healthy individuals were enrolled in this study. The Kolmogorov-Smirnov test was used to assess the distribution of variables. The Kruskal-Wallis H or Mann-Whitney U-tests were used to compare different sex, age, and geographical groups. The 95% reference ranges of PGs obtained by the two methods were established according to document CLSI-EP28-A3, with covariates of sex, age, and region. Spearman correlation analysis, linear regression analysis and allowable total error (ATE) zone analysis were utilized for comparing the two methods. On overall, the 95% reference ranges of PG-I, PG-II, and PGR measured by CLIA were 23.00-110.64 ng/mL, 2.50-19.13 ng/mL, and 3.87-13.30, respectively. Meanwhile, the reference ranges of PG-I, PG-II, and PGR measured by ELISA were 36.93-205.06 ng/mL, 1.65-17.96 ng/mL, and 7.50-33.60, respectively. Both PG-I and PG-II levels measured by the two platforms were found to be influenced by sex and age. PGR measured by CLIA was influenced by age but not by sex, while PGR measured by ELISA was not affected by either age or sex. Regional factors did not significantly impact the PG results, except for PG-I detected by ELISA. Ultimately, reference ranges for PGs were established based on age and sex stratification. Additionally, the Spearman correlation analysis revealed that the correlation coefficients for PG-I, PG-II, and PGR detected by the two methods were 0.899, 0.887, and 0.777, respectively, indicating a strong correlation between the two methods. The regression equation for the PG levels detected by two methods was obtained through linear regression analysis. The ATE analysis provided a visual depiction of the consistency between the two methods, clearly indicating the poor agreement between them. This study established the reference ranges of PGs by strict and intact enrollment standard. In addition, the results indicated a strong linear relationship between the two methods, yet with a clear bias, which was valuable for laboratory interpretation.

Development and Evaluation of a Cesarean Hysterectomy Simulation Model

Introduction: Cesarean hysterectomy is a life-saving procedure considered during postpartum hemorrhage in cases of uterine atony refractory to management, placenta accreta spectrum, or other obstetric complications. The procedure has high morbidity and mortality despite the rising rates of worldwide and in the United States. A high percentage of OB/GYN residents graduate without preparedness to perform this procedure post-residency, citing insufficient residency exposure as the primary contributor. This study aims to use evaluation and assessment tools to validate a low-cost, low-fidelity cesarean hysterectomy model at multiple OB/GYN residency training sites across the United States to increase resident confidence and proficiency in performing this critical procedure. Materials and Methods: Model Design and Development: Gynecologic surgeons from two OB/GYN residencies reviewed the literature for cesarean hysterectomy education and simulation. A low fidelity, anatomically accurate model was developed for cesarean hysterectomy simulation purposes. Efforts were made to optimize for anatomic layout and realistic feel, particularly for the anatomic structures relevant to cesarean hysterectomy: uterine vessels, anterior and posterior peritoneum, relation of anterior uterus to the bladder and ureters. Study Design: The study received institutional board review exemption at the Loyola University Medical Center (LUMC) and the University of Toledo (UT). During the last two months of the academic calendar, OB/GYN residents were offered the opportunity to perform a cesarean hysterectomy on the model. Demographics were collected in addition to the number of cesarean and abdominal hysterectomies performed as well as the confidence in cesarean hysterectomies independently. A uniform set of surgical instruments with both appropriate and inappropriate tools were made available for residents to choose from. Throughout the simulation, residents were asked to verbalize each step being performed. One faculty rater at each institution was trained to use the objective and standardized assessment tools and had completed an inter- and intra-rater reliability assessment. All residents were evaluated using the same two objective assessment tools. The two validated assessment tools used to evaluate resident performance using the model were the Task Specific Checklist and the Global Rating Scale. The former assessed residents on a “performed or not” basis on 14 surgical steps specific to cesarean hysterectomy. The latter used a scale of 1 to 5, with higher values representing more advanced skill, to evaluate respect for tissue handling, time and motion, instrument handing, knowledge of instrument selection, operation flow, assistant use, and familiarity with the procedure. Results: A total of 26 residents, 18 of 19 at LUMC and 8 of 17 at UT, completed the cesarean hysterectomy simulation between May and June 2022. At LUMC, no graduating residents had performed a cesarean hysterectomy in their residency. At UT, graduating residents had performed up to 2. All of the residents, including PGY-4s, stated that they either disagree or strongly disagree with the statement “I feel confident performing cesarean hysterectomy independently.” As hypothesized, the median resident scores on the Task Specific Checklist and Global Rating scale correlated with increasing PGY level. The combined TSC+GRS score was a median of 40 out of 49 total for the PGY-4 class, while the PGY-1 class had a median combined TSC+GRS score of 12 of 49. The PGY-2 and -3 class had TSC+GRS scores of 14 and 28 respectively. The simulation model was well-received with a median 4/5 rating for improving comfort level with cesarean hysterectomy and a median 4/5 rating for model realism. Each uterine model cost $6.00 and took approximately 20 minutes to build. The optional base constructed for supporting the model, cost a one-time fee of $160. All materials used for construction were easily available online. Discussion: This study validated an affordable, easily reproducible model that highlights the most important anatomy relevant to a cesarean hysterectomy. The model was developed, produced, and tested at two residency programs with a total of 26 residents participating in the study. This is the first low-fidelity cesarean hysterectomy model inclusive of relevant surgical steps and offers near-real visceral feel that has been developed and assessed for validity. This multisite study created a realistic model with high reproducibility at a low cost. Limitations of this study included the fact that only 27 residents participated in the study from only two institutions. In addition, faculty evaluators were not blinded to the residents they rated. The model is a reliable and affordable way to introduce this procedure at residency programs, particularly those that do not perform a substantial number of cesarean hysterectomies.

Accuracy of OBGYN Resident Physician Clinical Estimation of Fetal Weight in Term Pregnancies Before and After a Teaching Curriculum

Purpose: Accurate prediction of fetal birth weight can improve antepartum and intrapartum shared decision-making with patients. Therefore, this study primarily sought to determine if OBGYN residents are more accurate at clinically estimating fetal weight via Leopold maneuvers following a teaching curriculum including a hands-on simulation model. Secondary aims were to determine if accuracy changes depending on training level, maternal or fetal characteristics. Methods: A paired t-test was used to evaluate the primary aim of the teaching curriculum’s effect on accuracy of correct fetal weight estimation. Nineteen residents served as their own controls to assess differences in accuracy by performing 10-12 estimates prior to and after the teaching curriculum. The curriculum consisted of a short verbal workshop with images of how to perform Leopold maneuvers, along with five models that were created to represent a gravid uterus with a fetus measured in the 5th, 25th, 50th, 75th, 95th percentiles. Residents were also tested on models with unknown weights to confirm accuracy prior to completing the teaching curriculum. The inclusion criteria during the fetal weight estimates pre- and post-curriculum was as follows: mother had to deliver during hospital admission; gestational age was between 37 weeks and 41 weeks; singleton pregnancy; mother had not undergone rupture of membranes; mother was English speaking. Accuracy was defined as estimated fetal weight within 10% of actual birth weight. Generalized Logistic Mixed Models were used to assess accuracy when adjusting for PGY level, maternal and fetal characteristics. Maternal characteristics including age, BMI, race, pregestational diabetes, gestational diabetes, polyhydramnios, and oligohydramnios were abstracted from maternal medical charts via retrospective chart review. Infant characteristics including fetal macrosomia, fetal growth restriction, and gestational age were also recorded. Analyses were conducted using SAS 9.4; all p-values were two-sided and p-values &lt;0.05 were deemed statistically significant. Results: Nineteen OBGYN residents performed a total of 443 Leopold maneuvers to estimate fetal weight. Overall, resident estimation accuracy within 10% of actual birth weight improved from 65.5% to 67.4% (p=0.49) after the teaching curriculum. Senior residents showed a greater improvement after the teaching curriculum than junior residents, however it was not statistically significant. This could be due to the low sample size. Increasing gestational age was associated with higher odds of accurate estimation of fetal weight (OR 1.34, p=0.0295). There were no other differences in accuracy based on other maternal or fetal factors. Conclusion: The teaching of Leopold maneuvers is often not formalized in residency programs. This study did not show the expected improvement in accuracy of fetal weight estimation. Considerations that may impact clinical estimations include improving the simulation model, revising the teaching curriculum, and/or doing the teaching curriculum more frequently. Incorporating this hands-on simulation annually within the residency program educational curriculum to standardize the learning experience may be beneficial.

Risk factors and outcomes associated with external ventricular drain related hemorrhage

ObjectiveThe objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost. MethodsAfter Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors’ institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement. ResultsFrom this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions. ConclusionThe number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.

Gender influences resident physicians’ perception of an employee-to-employee recognition program: a mixed methods study

BackgroundBurnout is prevalent in medical training. While some institutions have implemented employee-to-employee recognition programs to promote wellness, it is not known how such programs are perceived by resident physicians, or if the experience differs among residents of different genders.MethodsWe used convergent mixed methods to characterize how residents in internal medicine (IM), pediatrics, and general surgery programs experience our employee-to-employee recognition ("Hi-5″) program. We collected Hi-5s received by residents in these programs from January 1, 2021–December 31, 2021 and coded them for recipient discipline, sex, and PGY level and sender discipline and professional role. We conducted virtual focus groups with residents in each training program.Main measures and approachWe compared Hi-5 receipt between male and female residents; overall and from individual professions. We submitted focus group transcripts to content analysis with codes generated iteratively and emergent themes identified through consensus coding.ResultsOver a 12-month period, residents received 382 Hi-5s. There was no significant difference in receipt of Hi-5s by male and female residents.Five IM, 3 surgery, and 12 pediatric residents participated in focus groups. Residents felt Hi-5s were useful for interprofessional feedback and to mitigate burnout. Residents who identified as women shared concerns about differing expectations of professional behavior and communication based on gender, a fear of backlash when behavior does not align with gender stereotypes, and professional misidentification.ConclusionsThe “Hi-5” program is valuable for interprofessional feedback and promotion of well-being but is experienced differently by men and women residents. This limitation of employee-to-employee recognition should be considered when designing equitable programming to promote well-being and recognition.

A nomogram model for the occurrence of bladder spasm after TURP in patients with prostate enlargement based on serum prostacyclin and 5-hydroxytryptamine and clinical characteristics.

With the development of analytical methods, mathematical models based on humoral biomarkers have become more widely used in the medical field. This study aims to investigate the risk factors associated with the occurrence of bladder spasm after transurethral resection of the prostate (TURP) in patients with prostate enlargement, and then construct a nomogram model. Two hundred and forty-two patients with prostate enlargement who underwent TURP were included. Patients were divided into Spasm group (n=65) and non-spasm group (n=177) according to whether they had bladder spasm after surgery. Serum prostacyclin (PGI2) and 5-hydroxytryptamine (5-HT) levels were measured by enzyme-linked immunoassay. Univariate and multivariate logistic regression were used to analyze the risk factors. Postoperative serum PGI2 and 5-HT levels were higher in patients in the Spasm group compared with the Non-spasm group (P<0.05). Preoperative anxiety, drainage tube obstruction, and elevated postoperative levels of PGI2 and 5-HT were independent risk factors for bladder spasm after TURP (P<0.05). The C-index of the model was 0.978 (0.959-0.997), with a χ2 = 4.438 (p = 0.816) for Hosmer-Lemeshow goodness-of-fit test. The ROC curve to assess the discrimination of the nomogram model showed an AUC of 0.978 (0.959-0.997). Preoperative anxiety, drainage tube obstruction, and elevated postoperative serum PGI2 and 5-HT levels are independent risk factors for bladder spasm after TURP. The nomogram model based on the aforementioned independent risk factors had good discrimination and predictive abilities, which may provide a high guidance value for predicting the occurrence of bladder spasm in clinical practice.

Protein profile analysis of tension wood development in response to artificial bending and gravitational stimuli in Betula platyphylla

Betula platyphylla Suk (birch) is an excellent short-term hardwood species with growth and wood characteristics well suited to wood industries. To investigate the molecular mechanism of wood development in birch, a tension wood (TW) induced system was used to explore the regulatory mechanism at the protein level and identify the key proteins involved in xylem development in birch. The results of dyeing with Safranin O-Fast Green indicated that the cellulose content of TW was significantly higher than that of opposite wood (OW) or normal wood (NW), and the lignin content in TW was significantly lower than that in OW and NW after artificial bending of birch stems. Protein profile analysis of TW, NW and OW by iTRAQ revealed that there were 639 and 460 differentially expressed proteins (DEPs) between TW/OW and TW/NW, respectively. The DEPs were mainly enriched in tyrosine metabolism, glycolysis/gluconeogenesis, phenylalanine and tyrosine metabolism, phenylpropanoid and pyruvate metabolism, the pentose phosphate pathway, the citrate cycle (TCA cycle), fructose and mannose metabolism, carbon fixation in photosynthetic organisms, fatty acid biosynthesis, photosynthesis proteins and other pathways. The proteins in the citrate cycle were upregulated. The expression levels of PGI, PGM and FRK proteins related to cellulose synthesis increased and the expression levels of PAL, 4CL and COMT related to lignin synthesis decreased, leading to an increase in cellulose content and decreased lignin levels in TW. PPI analysis revealed that key DEPs interact with each other, indicating that these proteins form complexes to implement this function, which may provide important insights for wood formation at the molecular level.

Evaluating Trainees' Experiences with Intravenous Iron Use

Background: Iron deficiency (ID) and iron deficiency anemia (IDA) cause significant morbidity. Despite being a disease of high prevalence, affecting people with heart failure, chronic kidney disease, heavy menstrual bleeding, irritable bowel disease, hereditary hemorrhagic telangiectasia (HHT), and bariatric surgery, it has low healthcare priority. The World Health Organization (WHO) estimates 37% of people who are pregnant, and 30% of women 15-49 years of age worldwide are anemic. Fibroids, which are the leading cause of abnormal uterine bleeding, disproportionately impact people of color. ID and IDA cause fatigue, impaired cognitive function, and poor mental health, eroding quality of life and personal productivity. In addition, IDA has been associated with an increase in all-cause mortality is associated with an increased risk of arterial and venous thrombosis. Under-treatment of IDA results in avoidable hospitalizations, emergency room visits, blood transfusions, decreased HRQoL, and loss of personal productivity. Despite the significant impact ID and IDA can have on morbidity, mortality, and quality of life, intravenous iron remains underutilized. No study has been performed to date to assess provider practices, knowledge, and perceptions of intravenous iron use. This qualitative study aims to understand trainees' experiences with intravenous iron use in patients with ID and IDA. Methods: We conducted an inductive reflective thematic analysis of semi-structured qualitative interviews from five focus groups to understand trainees' experiences with and barriers to prescribing intravenous iron in patients with ID and IDA. Internal medicine residents from academic institutions across the country were recruited via snowball sampling. Chief residents from six internal medicine programs were contacted to disseminate sign up links to their residents; programs were chosen for geographic diversity. Results: Twenty-eight internal medicine residents responded and nineteen residents across five institutions participated (PGY levels 1-3). Thematic analysis of trainees' experiences of caring for patients with conditions characterized by iron deficiency resulted in three main themes: education, systemic factors, and practice pattern. Participants identified a wide range of conditions for which they consider administration of oral or intravenous iron. However, they generally expressed uncertainty as to whether evidence-based guidelines exist to guide their decision-making with the exception of intravenous iron administration in heart failure patients. In addition, systemic factors, such as setting, support staff, hospital formularies, order sets, and insurance status often impacted their decision to use intravenous iron. Conclusions: There is a wide variation among residents' practice patterns in regard to their comfort with prescribing intravenous iron. The ease or hesitancy with which they do so is greatly influenced by educational and systemic factors. By gaining a deeper understanding of the experiences of trainees we can lay the foundation to develop evidence-based guidelines and educational initiatives for conditions characterized by ID and IDA. Additionally, by identifying both institutional facilitators and barriers, we can cultivate system-based initiatives to improve access to intravenous iron. To assess this need on a larger scale, our next step involves developing a survey that will be widely distributed via national societies. While cost, insurance status, and need for specialty referral were identified as barriers for intravenous iron use, there was no explicit discussion of how these barriers may contribute to healthcare inequity for underserved populations.

A reusable, low-cost model to improve resident confidence in performance of postpartum tubal ligation

Proficiency in postpartum abdominal sterilization is a core objective that residents must acquire during residency as outlined by the Council on Resident Education in Obstetrics and Gynecology. Surgical sterilization remains a popular and effective form of contraception in the United States; however, many women requesting immediate postpartum tubal ligation are unable to have the procedure given institutional barriers and variations in practice. Additionally, increasing use of long-term reversible contraceptives has contributed to declining immediate postpartum sterilization rates, which may ultimately impact an Obstetrics and Gynecology resident’s ability and confidence to perform this procedure. Our goal was to develop a reusable, low-cost model to improve resident familiarity and confidence with postpartum tubal ligation. A 3-dimensional model was developed that represents key anatomic structures encountered during tubal ligation and allows residents to perform all procedure steps. Materials and costs were determined. The model was piloted during scheduled simulation time. Residents evaluated the model’s realism and reported confidence in performing the tubal ligation pre- and post-simulation with a 5-point Likert scale . Four reusable models were created for $21.56 each. All PGY level residents (n=12) successfully performed the procedure with most having performed less than 5 postpartum tubal ligations previously. Resident confidence in performing postpartum tubal ligation improved significantly post-simulation (2.58 vs 3.42/5, p=0.005). Residents strongly agreed that the model replicated the steps (4.83/5), resembled the abdominal wall (4.58/5) and peritoneal cavity (4.73/5), and was similar in difficulty to a live procedure (3.2/5). All residents strongly agreed practicing on this model could improve surgical technique (5/5). This model fills a gap in sterilization simulation and resident training. It is low-cost and easily reproducible, closely resembles the pelvic anatomy, allows for completing the steps of the procedure and can be used for resident education to improve confidence with immediate postpartum sterilization.