M. Blair Marshall

Incorporating three-dimensional printing into a simulation-based congenital heart disease and critical care training curriculum for resident physicians.

OBJECTIVEnAlthough simulation-based education is now commonly utilized in medicine, its use in the instruction of congenital heart disease remains limited. The objective of this study is to evaluate whether heart models created with three-dimensional printing technology can be effectively incorporated into a simulation-based congenital heart disease and critical care training curriculum for pediatric resident physicians.nnnDESIGNnUtilizing heart models created with a three-dimensional printer, pediatric residents participated in a 60-minute simulation seminar with three consecutive components: (1) didactic instruction on ventricular septal defect anatomy; (2) didactic/simulation-based instruction on echocardiographic imaging of ventricular septal defects and anatomical teaching/operative simulation of ventricular septal defect repair; (3) simulation-based instruction on postoperative critical care management of ventricular septal defects.nnnSETTINGnAcademic, free-standing, childrens hospital with quaternary care referrals.nnnPARTICIPANTSnTwenty-three pediatric resident physicians.nnnOUTCOME MEASURESnSubjective, Likert-type questionnaires assessing knowledge acquisition, knowledge reporting, and structural conceptualization of ventricular septal defects.nnnRESULTSnThree-dimensional printing technology was successfully utilized to create heart models of five common ventricular septal defect subtypes. After using these models in a simulation-based curriculum, pediatric residents were found to have improvement in the areas of knowledge acquisition (P = .0082), knowledge reporting (P = .01), and structural conceptualization (P < .0001) of ventricular septal defects, as well as improvement in the ability to describe and manage postoperative complications in ventricular septal defect patients in the critical care setting.nnnCONCLUSIONSnThe utilization of three-dimensional printing in a simulation-based congenital heart disease and critical care training curriculum is feasible and improves pediatric resident physicians understanding of a common congenital heart abnormality.

Utilizing three-dimensional printing technology to assess the feasibility of high-fidelity synthetic ventricular septal defect models for simulation in medical education

Background: The current educational approach for teaching congenital heart disease (CHD) anatomy to students involves instructional tools and techniques that have significant limitations. This study sought to assess the feasibility of utilizing present-day three-dimensional (3D) printing technology to create high-fidelity synthetic heart models with ventricular septal defect (VSD) lesions and applying these models to a novel, simulation-based educational curriculum for premedical and medical students. Methods: Archived, de-identified magnetic resonance images of five common VSD subtypes were obtained. These cardiac images were then segmented and built into 3D computer-aided design models using Mimics Innovation Suite software. An Objet500 Connex 3D printer was subsequently utilized to print a high-fidelity heart model for each VSD subtype. Next, a simulation-based educational curriculum using these heart models was developed and implemented in the instruction of 29 premedical and medical students. Assessment of this curriculum was undertaken with Likert-type questionnaires. Results: High-fidelity VSD models were successfully created utilizing magnetic resonance imaging data and 3D printing. Following instruction with these high-fidelity models, all students reported significant improvement in knowledge acquisition (P < .0001), knowledge reporting (P < .0001), and structural conceptualization (P < .0001) of VSDs. Conclusions: It is feasible to use present-day 3D printing technology to create high-fidelity heart models with complex intracardiac defects. Furthermore, this tool forms the foundation for an innovative, simulation-based educational approach to teach students about CHD and creates a novel opportunity to stimulate their interest in this field.

Perceptions of gender-based discrimination during surgical training and practice

Background Women represent 15% of practicing general surgeons. Gender-based discrimination has been implicated as discouraging women from surgery. We sought to determine womens perceptions of gender-based discrimination in the surgical training and working environment. Methods Following IRB approval, we fielded a pilot survey measuring perceptions and impact of gender-based discrimination in medical school, residency training, and surgical practice. It was sent electronically to 1,065 individual members of the Association of Women Surgeons. Results We received 334 responses from medical students, residents, and practicing physicians with a response rate of 31%. Eighty-seven percent experienced gender-based discrimination in medical school, 88% in residency, and 91% in practice. Perceived sources of gender-based discrimination included superiors, physician peers, clinical support staff, and patients, with 40% emanating from women and 60% from men. Conclusions The majority of responses indicated perceived gender-based discrimination during medical school, residency, and practice. Gender-based discrimination comes from both sexes and has a significant impact on women surgeons.Background Women represent 15% of practicing general surgeons. Gender-based discrimination has been implicated as discouraging women from surgery. We sought to determine womens perceptions of gender-based discrimination in the surgical training and working environment. Methods Following IRB approval, we fielded a pilot survey measuring perceptions and impact of gender-based discrimination in medical school, residency training, and surgical practice. It was sent electronically to 1,065 individual members of the Association of Women Surgeons. Results We received 334 responses from medical students, residents, and practicing physicians with a response rate of 31%. Eighty-seven percent experienced gender-based discrimination in medical school, 88% in residency, and 91% in practice. Perceived sources of gender-based discrimination included superiors, physician peers, clinical support staff, and patients, with 40% emanating from women and 60% from men. Conclusions The majority of responses indicated perceived gender-based discrimination during medical school, residency, and practice. Gender-based discrimination comes from both sexes and has a significant impact on women surgeons.

Programmed Death Ligand 1: A Step Toward Immunoscore for Esophageal Cancer

BACKGROUNDnThis study sought to evaluate the effect of tumor-infiltrating lymphocyte (TIL) density and programmed death ligand 1 (PD-L1) expression on the prognosis of esophageal cancer.nnnMETHODSnBanked tissue specimens from 53 patients who underwent esophagectomies for malignancy at a single institution over a 6-year period were stained for cluster of differentiation 3 (CD3), CD8, and PD-L1. Tumors were characterized as staining high or low density for CD3 and CD8, as well as positive or negative for PD-L1. TIL density and PD-L1 expression were analyzed in the context of survival, recurrence, and perioperative characteristics.nnnRESULTSnMedian follow-up was 823 days, with 92.5% survival and 26.8% recurrence rates. All tumors were adenocarcinomas. Neoadjuvant chemotherapy was given in 56.6% of cases, and neoadjuvant radiotherapy was given in 37.7%. High CD3 density was found in 83%, whereas high CD8 density was found in 56.6%. A total of 18.9% of the tumors stained positive for PD-L1. Survival was significantly shorter in Kaplan-Meier analysis for patients with primary tumors staining positive for PD-L1 (log rank: pxa0= 0.05). Multivariable analysis controlling for neoadjuvant therapy, TIL markers, PD-L1, age, and sex found no significant difference in recurrence or survival.nnnCONCLUSIONSnPositive staining for PD-L1 may be a prognostic marker for decreased survival in esophageal adenocarcinoma. Additional TIL cell types should be investigated for creation of an esophageal cancer Immunoscore. PD-L1 has potential as a therapeutic target.

Management Strategy for Patients With Chronic Subclavian Vein Thrombosis

We performed a systematic review to determine best practice for the management of patients with chronic or subacute subclavian vein thrombosis. This condition is best managed with surgical excision of the first rib followed by long-term anticoagulation. Interventional techniques aimed at restoring patency are ineffective beyond 2 weeks postthrombosis. Additional therapeutic options should be made based on the severity of symptoms as well as vein status. Patients with milder symptoms are given decompression surgery followed by anticoagulation whereas patients with more severe symptoms are considered for either a jugular vein transposition or saphenous patch based on the vein characteristics.

Laparoscopic intragastric approach for gastroesophageal leiomyoma and cancer

Laparoscopic intragastric surgery was first described by Ohashi. We report our technique in the management of gastroesophageal junction (GEJ) leiomyoma and superficial cancers. This technique allows for excellent exposure of the pathology of the GEJ with minimal dissection of the stomach or disruption of the vagi. For leiomyoma, all patients undergo endoscopic biopsy to rule out a gastrointestinal stromal tumor before local excision.