Sanda Tan

Integration of Mobile Technology in Educational Materials Improves Participation: Creation of a Novel Smartphone Application for Resident Education

OBJECTIVE Traditional education consists of didactics and book learning. Recently, technology has been integrated into graduate medical education, primarily in the form of simulation. The primary aim of this study was to investigate if a novel smartphone application using technology to engage learners would improve participation in an educational activity when compared with a daily e-mail format and how this use translated to performance on standardized testing. DESIGN The UF Surgery App (App), which is a smartphone application, was developed to deliver 2 questions from a general surgery educational database every weekday from October to February 2013. The App, developed for iOS, featured a notification alarm and a reminder icon to actively engage the learner. Learners who used the App responded to multiple-choice questions and were provided instantaneous feedback in the form of a correct answer with an explanation. The response rate and answers were collected prospectively and compared with the American Board of Surgery In-Training Examination score. SETTING University of Florida, College of Medicine, Gainesville, Florida, a university teaching hospital. PARTICIPANTS A total of 46 general surgical residents were enrolled in a university training program. Participation was voluntary. RESULTS Overall, 26 of 46 (57%) residents participated. Of the users, 70% answered more than 20% of the questions, while 46% responded to more than 70% of questions. The percentage of correct answers on the App was positively correlated with standardized score (p = 0.005), percentage correct (p = 0.02), and percentile (p = 0.034) on the ABSITE examination. CONCLUSIONS Technology can be used to actively engage residents. Deployment of this novel App improved participation over a daily question-answer e-mail format, and answers correlated with standardized test performance. The effect of the App on overall education is unclear, and a multi-institutional study has been initiated.

The Subspecialization of Surgery: A Paradigm Shift

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by “specialists”. The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Total Neoadjuvant Therapy: A Shifting Paradigm in Locally Advanced Rectal Cancer Management

Abstract Colorectal carcinoma is the second leading cause of cancer‐related deaths in the United States, with rectal cancer accounting for approximately one‐third of newly diagnosed cases, thus representing a major socioeconomic health burden. Although minimally invasive procedures (ie, transanal excision) may be appropriate for a subset of patients with small, superficially invasive tumors, a more comprehensive trimodality approach with neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy is recommended for medically operable patients with nonmetastatic, locally advanced rectal cancer (LARC). Although such multimodality therapy has markedly reduced local recurrence rates, there remains an estimated 5‐year distant relapse rate of 35%, representing the leading cause of death in this population. This review critically assesses the literature regarding neoadjuvant therapy for LARC, as well as the available evidence to support selective exclusion of individual modalities from the contemporary therapeutic paradigm, including controversies of nonoperative management, selective radiation sparing, and neoadjuvant systemic therapy. Through the review of existing data and the anticipated results of ongoing clinical trials, we outline the pragmatic opportunities for future investigation into questions of efficacy, safety, and ultimate improvements to the current status quo.

Enrichment of IL-17A (+) IFN-γ (+) and IL-22 (+) IFN-γ (+)T cell Subsets Is Associated with Reduction of NKp44 (+) ILC3s in the Terminal Ileum of Crohn's Disease Patients

Crohns disease (CD) is a chronic inflammatory condition of the human gastrointestinal tract whose aetiology remains largely unknown. Dysregulated adaptive immune responses and defective innate immunity both contribute to this process. In this study, we demonstrated that the interleukin (IL)‐17A+interferon (IFN)‐γ+ and IL‐22+IFN‐γ+ T cell subsets accumulated specifically in the inflamed terminal ileum of CD patients. These cells had higher expression of Ki‐67 and were active cytokine producers. In addition, their proportions within both the IL‐17A‐producer and IL‐22‐producer populations were increased significantly. These data suggest that IL‐17A+IFN‐γ+ and IL‐22+IFN‐γ+ T cell subsets might represent the pathogenic T helper type 17 (Th17) population in the context of intestinal inflammation for CD patients. In the innate immunity compartment we detected a dramatic alteration of both phenotype and function of the intestinal innate lymphoid cells (ILCs), that play an important role in the maintenance of mucosal homeostasis. In the inflamed gut the frequency of the NKp44–CD117–ILC1s subset was increased significantly, while the frequency of NKp44+ILC3s was reduced. Furthermore, the frequency of human leucocyte antigen D‐related (HLA‐DR)‐expressing‐NKp44+ILC3s was also reduced significantly. Interestingly, the decrease in the NKp44+ILC3s population was associated with an increase of pathogenic IL‐17A+IFN‐γ+ and IL‐22+IFN‐γ+ T cell subsets in the adaptive compartment. This might suggest a potential link between NKp44+ILC3s and the IL‐17A+IFN‐γ+ and IL‐22+IFN‐γ+ T cell subsets in the terminal ileum of CD patients.

Cost effectiveness of a novel attempt to reduce readmission after ileostomy creation

Background and Objectives: Dehydration is a common complication after ileostomy creation and is the most frequent reason for postoperative readmission to the hospital. We sought to determine the clinical and economic impact of an outpatient intervention to decrease readmissions for dehydration after ileostomy creation. Methods: All new ileostomates from 09/2011 through 10/2012 at the University of Florida were enrolled to receive an ileostomy education and management protocol and a daily telephone call for 3 weeks after discharge. Counseling and medication adjustments were provided, with a satisfaction survey at the end. Outcomes of these patients were compared to those in a historical control cohort. A cost analysis was conducted to calculate the savings to the hospital. Results: Thirty-eight patients were enrolled. All patients required telephone counseling, and the mean satisfaction score rating was 4.69, on a scale of 1 to 5. The readmission rate for dehydration within 30 days of discharge decreased significantly from 65% before intervention to 16% (5/32 patients) after intervention (P = .002). The length of readmission hospital stay decreased from a mean of 4.2 days before the introduction of the intervention to 3 days after. Cost analysis revealed that the actual total hospital cost of dehydration-specific readmission decreased from

A novel method of minimally invasive rectus abdominis muscle flap harvest: Laparoscopic surgeons take note

88,858 to

Quantitative assessment of intestinal stiffness and associations with fibrosis in human inflammatory bowel disease

25,037, a saving of

Pre-operative total parenteral nutrition improves post-operative outcomes in a subset of Crohn’s disease patients undergoing major abdominal surgery

63,821. Conclusion: A standardized ileostomy pathway with comprehensive patient education and outpatient telephone follow-up is cost effective, has a positive influence on patient satisfaction, and reduces dehydration-related readmission rates.

Rectal cancer patients younger than 50 years lack a survival benefit from NCCN guideline-directed treatment for stage II and III disease: Survival in Rectal Cancer Patients < 50 Years Old

The rectus abdominis muscle (RAM) is a workhorse flap to fill or repair abdominal defects. A drawback of an open RAM harvest is donor site morbidity, and minimally invasive techniques for flap harvesting have been previously proposed but involve vertical division of the rectus fascia. We present a case of a 52-year-old woman with a recurrent rectovaginal fistula in a radiated field treated with a laparoscopic low anterior resection with simultaneous RAM flap harvest utilising a single Pfannenstiel incision. Our novel modified laparoscopic-assisted RAM harvest technique prevents longitudinal violation of the anterior and posterior rectus sheaths, thereby promoting a quick recovery, improved cosmesis and decreased post-operative morbidity.

Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy

Inflammatory bowel disease (IBD) continues to increase in prevalence in industrialized countries. Major complications of IBD include formation of fibrotic strictures, fistulas, reduced absorptive function, cancer risk, and the need for surgery. In other chronic gastrointestinal disease models, stiffness has been shown to precede fibrosis; therefore, stiffness may be a reasonable indicator of progression toward stricture formation in IBD patients. Herein, we seek to quantify tissue stiffness and characterize fibrosis in patients with IBD and to compare mechanical properties of unaffected human tissue to common animal species used for IBD studies. Inflamed and unaffected tissue from IBD patients and unaffected tissue from mice, pigs, and cows were indented using a custom device to determine the effective stiffness. Histology was performed on matched tissues, and total RNA was isolated from IBD tissue samples and used for gene expression analysis of pro-fibrotic genes. We observed an increase in the effective stiffness (steady-state modulus, SSM) (p < 0.0001) and increased expression of the collagen type I gene (COL1A1, p = 0.01) in inflamed tissue compared to unaffected areas in our IBD patient cohort. We also found that increased staining of collagen fibers in submucosa positively correlated with SSM (p = 0.093). We determined that unaffected animal bowel stiffness is significantly greater than similar human tissues, suggesting additional limitations on animal models for translational investigations regarding stiffness-related hypotheses. Taken together, our data support development of tools for evaluation of bowel stiffness in IBD patients for prognostic applications that may enable more accurate prediction of those who will develop fibrosis and more precise prescription of aggressive therapies.