Trinity Health Ann Arbor Hospital

Abstract Quality modern colorectal surgery education demands more than simply teaching technical skills; it requires a deep understanding of how surgeons learn. This article explores foundational pedagogical theories that support effective instruction across all stages of surgical training. Cognitive load theory, behaviorist models, and constructivist approaches such as experiential and social learning are examined for their relevance to surgical education. Deliberate practice and mastery learning frameworks offer structured methods for developing procedural expertise. Teaching strategies such as simulation and feedback models are discussed to promote competence and autonomy. Additionally, the article considers emotional and motivational components of learning, highlighting the roles of self-efficacy, feedback, and reflective practice. By aligning educational practice with established theory, colorectal surgeons can more effectively train future colleagues and elevate standards of care, professionalism, and continuous learning in a dynamic healthcare landscape.

Abstract Introduction: Risankizumab is a selective IL-23 p19 antagonist recently FDA-approved for treating moderate-to-severe inflammatory bowel disease in June 2024. While generally well-tolerated, notable side effects include allergic reactions and upper respiratory tract infections. No secondary noninfectious interstitial lung disease (ILD) cases have been reported yet. We present the first known case of organizing pneumonia following Risankizumab therapy, highlighting the need to carefully monitor respiratory symptoms in this population. Case description: A 55-year-old female, a former light smoker with Crohn's disease and no prior respiratory symptoms or hospitalizations received her first two infusions of Risankizumab four weeks apart. Three weeks after the second infusion, she was hospitalized for acute hypoxic hypercapnic respiratory failure initially thought to be due to COPD exacerbation from pneumonia and undiagnosed sleep apnea. Cardiology evaluation ruled out heart failure, and an echocardiogram was normal. She received appropriate antibiotics and a short course of steroids. A follow-up chest CT revealed bilateral patchy ground-glass opacities with interlobular wall thickening, suggestive of organizing pneumonia. Despite ongoing respiratory symptoms and hypoxia for over a month, bronchoscopy results were unremarkable with negative cultures. Transbronchial biopsy showed mild reactive fibrosis without signs of neoplasm or infection. The patient was treated with a steroid taper for presumed cryptogenic organizing pneumonia and the third infusion of Risankizumab was canceled. A notable improvement in symptoms and imaging was seen on follow-up. Discussion: A meta-analysis examining respiratory adverse events associated with IL-23 antagonists in psoriasis patients reported no significant increase in the risk of lower respiratory tract infections (LRTIs) or noninfectious ILD. However, two retrospective studies have indicated an increased risk of drug-induced interstitial pneumonitis with Ustekinumab, an IL-12/23 antagonist. Currently, there is no evidence linking Risankizumab to noninfectious ILD. Although our patient was at risk for developing Crohn's disease-related ILD, she exhibited no respiratory symptoms before or during the initiation of Risankizumab therapy. The acute onset of respiratory symptoms, normal cardiac echo, and chest CT findings indicative of organizing pneumonia following the second infusion of Risankizumab, along with the persistence of symptoms despite appropriate treatment for presumed pneumonia and COPD exacerbation, could suggest drug-induced interstitial pneumonitis. As the first reported case, this prompts further exploration of the causal and pathophysiological relationship between Risankizumab and noninfectious ILD. Additionally, it underscores the potential benefits of early follow-up chest CT scans after initiating therapy to monitor for this adverse event.

INTRODUCTION: Prior studies show differences in posterior compartment structures on magnetic resonance imaging (MRI) between resting and straining in patients with pelvic organ prolapse when compared to age- and parity-matched controls (Lewicky-Gaupp 2010). Further, nulliparous older women (>70) have larger resting levator bowl volume than younger women (<40) (Swenson 2020). OBJECTIVE: In this MRI measurement technique development pilot study, we perform a detailed analysis of the posterior compartment structures at rest and with straining in young, nulliparous subjects without prolapse symptoms and compare these MRI measurements to their POP-Q measurements. METHODS: Six OBGYN physicians from differing institutions and career stages met weekly to learn pelvic floor MRI measurement techniques. Using an MRI biorepository, mid-sagittal images were analyzed at rest and with straining in nulliparous subjects aged <40 years without prolapse symptoms. We utilized 3D Slicer software (slicer.org) to measure posterior vaginal wall length (PVW), urogenital hiatus (UGH), levator hiatus (LH), levator plate length (LP), and levator bowl volume (LBV). Six independent evaluators, five of which were novices, performed measurements that were averaged, and interrater reliability was assessed using the intraclass correlation coefficient (ICC). Statistical analysis was performed using Python; independent t-test and Pearson correlation were utilized. RESULTS: Eleven subjects were available for analysis. Table 1 shows demographic characteristics. Compared with resting measurements, UGH (p<.001), LH (p<.001), and LBV (p<.001) increased with straining without significant change in LP or PVW length. There was a strong positive correlation between MRI posterior fornix location and PVW length (r=.77, p<.001). There was a strong negative correlation between MRI cervix location and POP-Q C (r= −0.70, p=.01) and MRI posterior fornix and POP-Q D (r=−0.697, p=.02). ICC was .95 indicating excellent interrater reliability (Figure 1). CONCLUSIONS: MRI allows visualization of real-time changes within the same subject and provides insight into the biomechanics of the pelvic floor beyond what can be learned from textbooks and cadaveric dissections. In young, nulliparous women without prolapse symptoms, MRI reveals dynamic changes in posterior compartment structures between rest and strain. During straining, there is relaxation of the pelvic floor shown by increased UGH, LH, and LBV. Although straining did not change the length of LP or PWV, it likely changed the orientation of the levator plate, as evidenced by the increase in LBV. The strong correlations between MRI measurement and POP-Q measures reflect that these measures describe the same phenomenon. The ICC for this study showed excellent interrater reliability, demonstrating that targeted education and training in pelvic MRI analysis produces precise and accurate measurement results among novice learners (Table 2).

Post-traumatic stress (PTS) symptoms are highly comorbid with substance use (i.e., alcohol, tobacco, and cannabis). Few studies have investigated potential individual-, household-, and neighborhood-level socioeconomic effect modifiers of this comorbidity in longitudinal analyses. We aim to examine interactions between this multi-level environment and PTS symptoms on future substance use behaviors. Data were drawn from the Advancing Understanding of RecOvery afteR traumA (AURORA) study, including 2943 individuals who presented to the emergency department (ED) within 72 h of a traumatic event. Frequency of tobacco, alcohol, cannabis use, and PTS symptoms were reported at 6 timepoints. Mixed effect Poisson models, clustered by state, were used to generate incidence rate ratios (IRRs) substance use, both cross-sectionally and prospectively. Moderation analysis of PTS and substance use, stratified by household income and area deprivation index (ADI), was conducted using mixed effect models and parallel process growth curves. Significant associations were observed between PTS with tobacco, alcohol, and cannabis use frequency cross-sectionally, and for tobacco and alcohol and PTS exposure prospectively. Lower income (P < 0.001) and higher deprivation (P < 0.001) were associated with tobacco use, while higher income (P < 0.001) and less deprivation (P = 0.01) were associated with increased alcohol use. We found modest modification by household income for alcohol and tobacco, and little evidence of modification by neighborhood ADI. Household income had greater evidence of effect modification for substance use, compared to neighborhood-level ADI. Our findings demonstrate that household indicators of socioeconomic status likely modify the relationship between PTS and substance use.

BackgroundThe specimen extraction incision is the largest during minimally invasive colectomy and conceivably the most painful. We recently adopted natural orifice extraction through the rectum or vagina, leaving only port site incisions for abdominal wall pain. Previous studies demonstrating natural orifice extraction advantages are inconclusive. The study aim was to determine if natural orifice specimen extraction is associated with less pain and opioid use than abdominal wall specimen extraction after enhanced recovery robotic anterior (sigmoid) resection for benign disease.MethodsThis is a single-institution retrospective analysis comparing abdominal wall and natural orifice extraction sites after robotic anterior resection for diverticular disease in a prospectively maintained institutional colorectal surgery database from 1/1/2021 to 11/21/2024. The primary outcomes were postoperative opioid use measured by morphine milliequivalents analyzed with generalized linear models and postoperative pain scores analyzed with ordinal logistic regression models.ResultsThere were 251 anterior (sigmoid) resections for diverticular disease, 136 patients with abdominal wall specimen extraction sites, and 115 patients with natural orifice extraction. Patient characteristics were well matched between groups. One-fifth (20.7%) of the study population required no postoperative opioids. There was no significant difference in postoperative opioids, measured by morphine milliequivalents, between natural orifice and abdominal wall extraction site groups (aOR1.21, p = 0.59). Lower preoperative pain (aOR0.73, p = 0.02) and better mental health (aOR1.05, p = 0.05) were associated with no postoperative opioids. Patient-reported preoperative PROMIS-10 pain scores and younger age were associated with higher postoperative numeric pain scores. There was no significant difference in postoperative complications between groups (abdominal wall 8.1% vs natural orifice 13.0%).ConclusionThere was no significant difference between abdominal wall and natural orifice extraction in postoperative pain, postoperative opioids, and complications after robotic anterior resection for diverticular disease. These data may assist targeting postoperative pain solutions and counsel patients considering specimen extraction site options.

ABSTRACT The prevalence of mental, emotional, and social health (MESH) challenges among youth in out-of-school time (OST) contexts is on the rise, exacerbated by the ongoing impact of the COVID-19 pandemic. In response to this escalation, recent literature has explored MESH concerns impacting youth program participants and young adult staff. This study focuses on participant and staff MESH issues within summer camps and the healthcare practices implemented by program providers to address those issues. Our four research questions are: (1) What are the characteristics of camper and staff MESH issues?; (2) What are characteristics of MESH medications managed in camps?; (3) How are camp providers preparing staff for camper MESH care?; and (4) How are camp providers responding to staff MESH care needs? Findings highlight prevalent MESH issues facing youth and young adult staff and program preparedness. Notably, our study affirmed that the most prevalent MESH issues facing youth and young adult staff are anxiety, ADHD, depression, and emotional regulation. Study findings also indicated that while many camps engage in pre-camp MESH trainings, a limited number revisit MESH topics during the summer work period. Collectively, these results offer key insights into camp providers’ experiences with youth and young adult staff MESH.