What is the best method of surgical training?: A report of America's leading senior surgeons

OBJECTIVES: To characterize the career choices and developments made by leading senior surgeons in this country and to examine hypothetically whether application of a short tracking program would have hindered their career decisions. DESIGN: A survey pertaining to each surgeon's career, decisions, and opinions concerning surgical training. SETTING AND PARTICIPANTS: Senior surgeons of regional and national surgical societies. MAIN OUTCOME MEASURE: Survey responses. RESULTS: A total of 352 surveys (41.4%) were received. Respondents answered that the most common reasons for choosing a specialty were role models or mentors (56%), research (51%), and available patient population (23%). The 2 most common stages in a career at which the respondents became interested in a specialty, or an area of expertise, were at the junior residency level (when the specialty was chosen) and at the assistant professor level (when a more specific topic within the specialty was chosen). The most common stage at which the group believed they acquired their expertise was also at the assistant professor level. Seventy-one percent of respondents believed broad training was superior to a short tracking system, although none had participated in shortened surgical training. CONCLUSIONS: Most leading senior surgeons in this country still believe that broad surgical training is superior and should be maintained. Because career specialties in this surveyed group were generally chosen in early residency, a hypothetical application of the short tracking system would have still allowed for these important decisions to be made. Also, it seems likely that specialty and career development would not have been hindered because "expertization" mostly occurred after training was completed. Regardless of training method, a role model or mentor seems most important in career choices and developments.     

Solid-state 2H NMR study of methyl-d3-cobalamin

A solid-state 2H NMR study of methyl-d3-cobalamin has been performed as a function of temperature to provide information concerning the character and energetics of the motion performed by this unique bioorganometallic methyl group. Analysis of the 2H NMR line shape indicates that the methyl group undergoes rapid three-fold rotation, and that the Co-C-2H angle lies between 105.9 and 109.5 degrees. Determination of the spin-lattice relaxation times T1 shows that the relaxation is anisotropic, consistent with a "jumping" motion of the methyl group rather than rotational diffusion. This also provides the activation energy to methyl jumps as 8.3 +/- 1.3 kJ/mol. It is proposed that this energetic barrier may be a useful probe of changes in the electronic character of the Co-C bond that accompany the biological role of this molecule in such enzymes as methionine synthase.     

CTA-based angle selection for diagnostic and interventional angiography of saccular intracranial aneurysms

Coil embolization is a safe treatment for cerebral aneurysms only if the width of the neck in relation to the fundus of the aneurysm is small. Therefore, accurate visualization of the aneurysmal neck is required both in the diagnostic process and during the intervention. Conventional digital subtraction angiography (DSA) is still the preferred modality for the examination of cerebrovascular abnormalities like aneurysms, but it often does not provide the required morphological characteristics due to the suboptimal selection of projection angles and resulting overprojections of surrounding vasculature. This paper presents a method for performing a computer-assisted calculation of the optimal projection angles for DSA by post-processing computed tomographic angiography (CTA) volume data using ray-casting techniques and a combination of image processing algorithms. By means of phantom studies, retrospective simulations of angiograms, and in vivo applications of calculated optimal viewing angles, it is demonstrated that the proposed method results in better angiographic projections of the neck of saccular aneurysms with small neck-fundus ratio than those acquired at standard angles prescribed by clinical protocols.     

Intracellular events determine the fate of antithrombin Utah

We sought to determine whether intracellular or extracellular events contribute to the decrease in circulating antithrombin (AT) levels that is seen in subjects with the Utah mutation (Pro 407 to Leu). Site-directed mutagenesis was used to recreate this mutation within a previously characterized rabbit AT cDNA. Cell-free expression of the mutated cDNA yielded an AT protein that failed to react with thrombin. Expression of the rabbit AT-Utah protein in transiently transfected Cos cells resulted in a 10-fold decrease in the amount of AT antigen detected in the conditioned media, as compared with that seen with the wild-type recombinant AT. This effect was not caused by variations in transfection efficiency, because AT levels were normalized to the product of a cotransfected plasmid, chloramphenicol acetyl transferase. Moreover, on Northern blot analysis, AT mRNA levels were comparable in cells expressing either the rabbit AT-Utah or wild-type recombinant rabbit AT. Immunoblots of conditioned media from the two populations of transfected cells showed that the recombinant AT-Utah protein was intact. The results obtained with Cos cells were reproduced using permanently transfected Chinese hamster ovary (CHO) cells. Pulse-chase experiments with the CHO lines showed that both initial levels of rabbit AT-Utah after the pulse labeling and the rate of subsequent secretion during the chase period were reduced compared with that seen with cells expressing the wild-type AT. The observed reduction in AT secretion was also observed for the AT-Oslo mutation (Ala 404 to Thr) when recreated in the rabbit AT background, and expressed in Cos cells. In these experiments, the media levels of mutant AT were reduced by 50%, compared with wild-type. These results show that intracellular events, as opposed to accelerated clearance or other extracellular causes, contribute to the paucity of AT secretion seen in these strand 1C AT mutants.     

High-resolution MR imaging of stage I cervical neoplasia with a dedicated transvaginal coil: MR features and correlation of imaging and pathologic findings

OBJECTIVE: The purposes of this study were to assess the appearance of stage 1 neoplasia of the cervix by high-resolution MR imaging with an enveloping transvaginal receiver coil and to correlate the imaging findings with the pathologic findings. SUBJECTS AND METHODS: Fifteen patients (25-73 years old; mean, 40 years old) with clinical stage I disease were examined with a 37-mm-diameter ring-design solenoid receiver coil placed around the cervix. Axial 2.5-mm contiguous slices were obtained with a field of view of 10-15 cm on a 1.0-T HPQ Vista scanner with T1-weighted (660/20 msec [TR/TE]) and T2- weighted (2500/80 msec) spin-echo sequences and dynamic gradient-echo sequences during injection of gadopentetate dimeglumine (0.1 mmol/kg). Ten patients subsequently underwent Wertheim's hysterectomy, two underwent radiotherapy, two underwent extended cone biopsy for microinvasive disease, and one underwent a punch biopsy. For seven of 10 patients who had a hysterectomy, the widths of the tumor and the residual stroma were measured at eight radial points on the transverse images and at corresponding points on the histologic specimens at 5, 10, 15, 20, and 25 mm from the ectocervix. We then compared the widths of the tumor and the stroma on images and histologic specimens at each of these 40 points. Tumor volumes were calculated from the MR imaging and pathologic data and compared. For the other three patients, detailed MR imaging-pathology correlation was not possible because of multifocal tumor distribution (two patients) and insufficient detailed pathologic data (one patient). RESULTS: Three carcinoma types were recognized. Squamous carcinoma (nine cases) was seen as a centrally expanding intermediate-signal-intensity mass, whereas oat (small)-cell carcinoma (one case) and clear-cell carcinoma (one case) showed a multifocal distribution. For patients who had a radical hysterectomy, we noted good agreement between the widths of the tumor and the stroma determined by MR imaging and histology. Tumor volumes were determined to be 0-28.2 cm3 by MR imaging and 0-18.4 cm3 by pathology. We observed tumor extension into the immediate parametrium in four patients by MR imaging; one of these cases was not confirmed at surgery. Parametrial extension was not underestimated by MR imaging in any case. CONCLUSION: High-resolution imaging of the cervix with a transvaginal coil provides accurate assessment of the intra- and extracervical extents of tumors in clinical stage 1 cervical neoplasia.     

Responses of dairy cows supplemented with somatotropin during weeks 5 through 43 of lactation

Beginning at wk 5 of lactation, 136 cows (34 per treatment) were supplemented daily for 38 wk with 0, 10.3, 20.6, or 41.2 mg of recombinantly derived bST monomer. Cows were obtained from University of Kentucky, University of Minnesota, University of Pennsylvania, and The Ohio State University. Nine cows (4 at 0 mg/d, 1 at 10.3 mg/d, 1 at 20.6 mg/d, and 3 at 41.2 mg/d) did not complete the experiment because of health problems. Data from these cows were included in the reproduction and health databases but not in the production database. Cows supplemented with bST produced more milk, consumed more feed, had lower rates of BW gain, and had improved efficiencies of milk production (conversion of feed and NEL to milk). Additional increases in productivity were modest at 20.6 and 41.2 mg/d versus productivity at 10.3 mg/d of bST. Concentrations of fat, protein, and TS in milk were unaffected. At 10.3 mg/d, bST did not adversely affect reproduction or health.