Erika Simmerman

Feasibility and Benefit of Incorporating a Multimedia Cadaver Laboratory Training Program into a Didactics Curriculum for Junior and Senior Surgical Residents

OBJECTIVE As operative experience in general surgery decreases and work hour limitations increase there is less exposure of surgical residents to advanced vascular and trauma exposures. Many institutions have demonstrated benefits of cadaver laboratory courses. We have incorporated a multimedia cadaver laboratory course into our general surgery residency didactics curriculum with the objective to demonstrate a benefit of the program as well as the feasibility of incorporation. STUDY DESIGN This is a prospective study at a tertiary care institution including general surgery residents within our residency program. A curriculum was designed, requiring residents to complete multimedia learning modules before both a trauma cadaver laboratory and vascular exposure cadaver laboratory. Outcome measures included self-efficacy/confidence (precourse and postcourse 5-point Likert surveys), knowledge (net performance on precourse and postcourse multiple choice examinations), and resident perception of the curriculum (postcourse 5-point Likert survey). Data were analyzed using ANOVA paired t-tests. RESULTS For the vascular cadaver laboratory, resident knowledge improved overall from an average of 41.2% to 50.0% of questions correct (p = 0.032) and self-efficacy/confidence improved by 0.59 from 1.52 to 2.11 out of 5 (p = 0.009). Median confidence is 1.37 out of 5 and 2.32 out of 5, before and after course, respectively. Wilcoxon nonparametric test reveals a p = 0.011. Residents perception of the usefulness of the laboratory evaluation was 3.85 out 5. There were 85.71% agreed that the laboratory is useful and 14.29% were disagree. The Z-score is -0.1579 (means 0.1579 standard deviations a score of 3.85 below the benchmark). The percentile rank is 56.27%. The coefficient of variation is 24.68%. For the trauma cadaver laboratory, resident knowledge improved overall from an average of 55.89% to 66.17% of questions correct (p = 0.001) and self-efficacy/confidence improved by 0.75 from 1.68 out of 5 to 2.43 out of 5 (p = 0.011). Median confidence level is 1.41 out of 5 before the training course and 2.64 out of 5 after the training course. Wilcoxon signed rank test gives a p value of 0.008. Residents perception of the usefulness of the laboratory evaluation was 3.94 out 5. There were 72.22% agreed that the laboratory is useful and 27.78% were neutral. The Z-score is -0.098 (means 0.098 standard deviations a score of 3.94 below the benchmark). The percentile rank is 53.90%. The coefficient of variation is 15.48%. CONCLUSIONS Incorporating a multimedia cadaver laboratory into a residency education didactics curriculum was both feasible and beneficial for resident education. We demonstrate an improvement in knowledge and self efficacy/confidence following both cadaver laboratory courses.

The impact of Cannabidiol treatment on regulatory T-17 Cells and neutrophil polarization in Acute Kidney Injury

Hallmark features of acute kidney injury (AKI) include mobilization of immune and inflammatory mechanisms culminating in tissue injury. Emerging information indicates heterogeneity of neutrophils with pro- and anti-inflammatory functions (N1 and N2, respectively). Also, regulatory T-17 (Treg17) cells curtail T helper 17 (Th-17)-mediated proinflammatory responses. However, the status of Treg17 cells and neutrophil phenotypes in AKI are not established. Furthermore, cannabidiol exerts immunoregulatory effects, but its impact on Treg17 cells and neutrophil subtypes is not established. Thus, we examined the status of Treg17 cells and neutrophil subtypes in AKI and determined whether cannabidiol favors regulatory neutrophils and T cells accompanied with renoprotection. Accordingly, mice were subjected to bilateral renal ischemia-reperfusion injury (IRI), without or with cannabidiol treatment; thereafter, kidneys were processed for flow cytometry analyses. Renal IRI increased N1 and Th-17 but reduced N2 and Treg17 cells accompanied with disruption of mitochondrial membrane potential (ψm) and increased apoptosis/necrosis and kidney injury molecule-1 (KIM-1) immunostaining compared with their sham controls. Importantly, cannabidiol treatment preserved ψm and reduced cell death and KIM-1 accompanied by restoration of N1 and N2 imbalance and preservation of Treg17 cells while decreasing Th-17 cells. The ability of cannabidiol to favor development of Treg17 cells was further established using functional mixed lymphocytic reaction. Subsequent studies showed higher renal blood flow and reduced serum creatinine in cannabidiol-treated IRI animals. Collectively, our novel observations establish that renal IRI causes neutrophil polarization in favor of N1 and also reduces Treg17 cells in favor of Th-17, effects that are reversed by cannabidiol treatment accompanied with significant renoprotection.

Laparoscopy-Assisted PEC Tubes: A Novel Treatment for Sigmoid Volvulus

Introduction: In the United States, sigmoid volvulus is frequently seen in the elderly and neurologically impaired, driving a search for less invasive but effective treatments that may obviate the need for resection. This case study describes a novel technique for sigmoidopexy: a modified endoscopic approach for percutaneous endoscopic colostomy (PEC) tube placement in combination with laparoscopy for safety. Case Description: This is a case study reporting a novel technique. The subject was a 55-year-old man with a history of longstanding constipation and recurrent sigmoid volvulus. Because of religious beliefs, the family refused any surgical procedures requiring bowel resection. Thus, alternative methods for definitive treatment were sought. The patient underwent laparoscopic assisted PEC tube placement with placement of three colostomy tubes for sigmoidopexy. The procedure was tolerated well, and the patient had an uneventful postoperative course. With persistent symptoms of constipation and dysmotility, the colon could be vented and irrigated via the colostomy tubes. Two years after surgery the patient has all 3 PEC tubes in place without complication or recurrence of sigmoid volvulus. Conclusion: PEC tubes have been used for sigmoidopexy with various levels of success in the treatment of recurrent volvulus, but laparoscopic assistance in placement of 3 PEC tubes has not been documented. Laparoscopic assistance allows for reduction of volvulus and decreases complications associated with PEC tube placement. This case demonstrates a novel, safe technique for the treatment of sigmoid volvulus.

Abstract 3544: Determining autophagic activity following cannabidiol treatment of melanoma: a potential new and novel treatment

Introduction: Autophagy is a catabolic pathway utilized for energy metabolism in nutrient-depleted tumors. Recent studies have reported autophagy to be a survival mechanism found in cancer during stress secondary to cancer progression or treatment. In this study we tested for autophagic activity in malignant melanoma tumors via detection of LC3 antibody following treatment with Cannabidiol (CBD) and cisplatin. The objective of this study was to investigate the effect of treatment with a cannabinoid derivative on autophagic activity in malignant melanoma. Materials and Methods: Murine B16F10 melanoma tumors were established subcutaneously in C57BL/6 mice. These mice were then subjected to treatment with local vehicle (PBS) injection (control - group 1, n = 5), systemic Cisplatin injection (group 2; n = 5), and local cannabidiol injection (group 3; n = 5). Tumor cells were subsequently submitted to immunohistochemistry, Brightfield microscopy, and quantitative analysis (Bioquant) for LC3 expression. Results: The expression level of LC3 was significantly reduced in groups 2 and 3 when compared to the control group 1. Quantitative measurement of the slides using Bioquant software confirmed our immunohistochemistry and microscopic results. Conclusions: If CBD does indeed decrease autophagic activity, it may represent a new and novel therapeutic target in the treatment of malignant melanoma. Additional studies to clarify the specific relationship between CBD and autophagy are in progress and will be reported upon completion. Citation Format: Erika L. Simmerman, Xu Qin, Kouros Motamed, Jack C. Yu, Babak Baban. Determining autophagic activity following cannabidiol treatment of melanoma: a potential new and novel treatment. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3544.