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Introduction: SSL introduces ergonomic challenges while establishing the critical view during dissection of the Triangle of Calot (TOC). This study investigates the use of a novel percutaneous instrument platform and MAGS in performing SSL cholecystectomy with a technique that closely mimics four-port cholecystectomy.Methods: SSL cholecystectomy was performed on four female cadavers via a 15-18-mm incision made at the umbilicus for introduction of these devices and the working port. MAGS comprises an internal effector with a retractable monopolar cautery hook coupled across the abdominal wall to an external magnet held by the surgeon. The novel grasper was introduced percutaneously in the RUQ and comprises a 3-mm transabdominal shaft mated to a 5-mm end effector intracorporeally. Retraction was accomplished using the percutaneous grasper to manipulate the fundus and a standard 5-mm grasper at the umbilicus for the infundibulum. Dissection was performed by using a combination of the MAGS and a standard Maryland dissector. Total procedure time, time from procedure start to obtain a critical view of the TOC and clipping and dividing the cystic duct/artery, time for dissection of the gallbladder from the liver bed, and thickness of the abdominal wall at the umbilicus were measured.Results: The critical view was obtained in each case, and all four procedures were completed successfully. Mean procedure time was 40 (range, 33-51) min; time from procedure start to obtaining the critical view and clipping and dividing the cystic duct/artery was 33 (range, 28-38) min, and time for dissection of the gallbladder from the liver bed was 6.7 (range, 3-13) min. The mean abdominal wall thickness was 1.9 (range, 1.5-2) cm.Conclusions: The use of a novel graspers and MAGS overcomes the limitations of SSL cholecystectomy and improves surgeon dexterity. Making SSL feel more like traditional laparoscopy will enable a wider adoption of this procedure in the community. [ABSTRACT FROM AUTHOR]

Introduction: Single-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with wristed instruments could overcome this limitation, but the arms often collide when working coaxially. This study tests a new technique of "chopstick" surgery to enable use of the robotic arms through a single incision without collision.Methods: Experiments were conducted utilizing the da Vinci S robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a Fundamentals of Laparoscopic Surgery (FLS) box trainer with three laparoscopic ports (1 x 12 mm, 2 x 5 mm) introduced through a single "incision." Pilot work determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, five experienced robotic surgeons performed three FLS tasks utilizing either a standard robotic arm setup or the chopstick technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This results in separation of the robotic arms outside the box. To correct for the change in handedness, the robotic console is instructed to drive the "left" instrument with the right-hand effector and the "right" instrument with the left. Performances were compared while measuring time, errors, number of clutching maneuvers, and degree of instrument collision (Likert scale 1-4).Results: Compared with the standard setup, the chopstick configuration increased surgeon dexterity and global performance through significantly improved performance times, eliminating instrument collision, and decreasing number of camera manipulations, clutching maneuvers, and errors during all tasks.Conclusion: Chopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery. [ABSTRACT FROM AUTHOR]

The present study applied Weiss's theoretical framework to better understand interpersonal relationships between grandmothers and their young adult granddaughters. The questions that were of primary focus for the research addressed importance of the relationship provisions, predictors of relationship satisfaction, and variability in importance of closeness and instrumental support. The sample consisted of 48 grandmother-adult granddaughter pairs where the granddaughter was an undergraduate student at a Midwestern university. The Furman and Buhrmester Network of Relationships Inventory (NRI) was used to examine the relationships between grandmothers and their granddaughters. Grandmothers and granddaughters rated the perceived level of admiration, affection, reliable alliance, and relationship satisfaction higher in their relationship with each other than the other relationship provisions. Reliable alliance was rated as the highest relationship provision for grandmothers and granddaughters with the lowest rated being intimacy. The results of ordinary least squares (OLS) regression analyses show that these intergenerational relationships vary along provisions of closeness and instrumental support when predicting relationship satisfaction. These results suggest that programs designed to link generations of women should take into consideration the variability of their relationships. [ABSTRACT FROM AUTHOR]

Service learning provides students the opportunity to realistically assess the strengths of their professional knowledge and skills while contributing to services that address community needs. Process and product portfolios are proposed as tools for integration of thought and action as students analyze their service learning experiences. Ernest Boyer's concepts of the scholarship of integration and application are presented here as central to the portfolio development process. Student and faculty reports suggest portfolios are a successful tool for encouraging professional reflection and integration of service learning experiences. [ABSTRACT FROM AUTHOR]

The constructivist paradigm states that students have a basic need to understand their experiences and they are the center of the learning process while the instructor should only be the facilitator. Working and presentation portfolios support this approach by making students active participants in their learning and providing them with opportunities to reflect on their knowledge. Additionally, using portfolios within family science also helps clarify for both students and their potential employers what makes family science distinct from other related social science disciplines. The purpose of this article is to present the experience of how portfolios were introduced into the family science curriculum at a small Midwestern university. [ABSTRACT FROM AUTHOR]

Recognition of viral infection often relies on the detection of double-stranded RNA (dsRNA), a process that is conserved in many different organisms. In mammals, proteins such as MDA5, RIG-I, OAS, and PKR detect viral dsRNA, but struggle to differentiate between viral and endogenous dsRNA. This study investigates an shRNA targeting DDX54's potential to activate PKR, a key player in the immune response to dsRNA. Knockdown of DDX54 by a specific shRNA induced robust PKR activation in human cells, even when DDX54 is overexpressed, suggesting an off-target mechanism. Activation of PKR by the shRNA was enhanced by knockdown of ADAR1, a dsRNA binding protein that suppresses PKR activation, indicating a dsRNA-mediated mechanism. In vitro assays confirmed direct PKR activation by the shRNA. These findings emphasize the need for rigorous controls and alternative methods to validate gene function and minimize unintended immune pathway activation., (© 2024. The Author(s).)

Invertebrates use the endoribonuclease Dicer to cleave viral dsRNA during antiviral defense, while vertebrates use RIG-I-like Receptors (RLRs), which bind viral dsRNA to trigger an interferon response. While some invertebrate Dicers act alone during antiviral defense, Caenorhabditis elegans Dicer acts in a complex with a dsRNA binding protein called RDE-4, and an RLR ortholog called DRH-1. We used biochemical and structural techniques to provide mechanistic insight into how these proteins function together. We found RDE-4 is important for ATP-independent and ATP-dependent cleavage reactions, while helicase domains of both DCR-1 and DRH-1 contribute to ATP-dependent cleavage. DRH-1 plays the dominant role in ATP hydrolysis, and like mammalian RLRs, has an N-terminal domain that functions in autoinhibition. A cryo-EM structure indicates DRH-1 interacts with DCR-1's helicase domain, suggesting this interaction relieves autoinhibition. Our study unravels the mechanistic basis of the collaboration between two helicases from typically distinct innate immune defense pathways., Competing Interests: CC, AA, HD, PA, DE, PS, BB No competing interests declared, (© 2024, Consalvo et al.)

In this article, I recount my memories of key experiments that led to my entry into the RNA editing/modification field. I highlight initial observations made by the pioneers in the ADAR field, and how they fit into our current understanding of this family of enzymes. I discuss early mysteries that have now been solved, as well as those that still linger. Finally, I discuss important, outstanding questions and acknowledge my hope for the future of the RNA editing/modification field., (© 2024 Bass; Published by Cold Spring Harbor Laboratory Press for the RNA Society.)

Importance: Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex., Objective: To examine the association between surgeon sex and health care costs among patients undergoing surgery., Design, Setting, and Participants: This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023., Exposure: Surgeon sex., Main Outcome and Measure: The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates., Results: Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202)., Conclusions and Relevance: This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

The ability to sense and respond to infection is essential for life. Viral infection produces double-stranded RNAs (dsRNAs) that are sensed by proteins that recognize the structure of dsRNA. This structure-based recognition of viral dsRNA allows dsRNA sensors to recognize infection by many viruses, but it comes at a cost-the dsRNA sensors cannot always distinguish between "self" and "nonself" dsRNAs. "Self" RNAs often contain dsRNA regions, and not surprisingly, mechanisms have evolved to prevent aberrant activation of dsRNA sensors by "self" RNA. Here, we review current knowledge about the life of endogenous dsRNAs in mammals-the biosynthesis and processing of dsRNAs, the proteins they encounter, and their ultimate degradation. We highlight mechanisms that evolved to prevent aberrant dsRNA sensor activation and the importance of competition in the regulation of dsRNA sensors and other dsRNA-binding proteins., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To determine whether patient-surgeon gender concordance is associated with mortality of patients after surgery in the United States., Design: Retrospective observational study., Setting: Acute care hospitals in the US., Participants: 100% of Medicare fee-for-service beneficiaries aged 65-99 years who had one of 14 major elective or non-elective (emergent or urgent) surgeries in 2016-19., Main Outcome Measures: Mortality after surgery, defined as death within 30 days of the operation. Adjustments were made for patient and surgeon characteristics and hospital fixed effects (effectively comparing patients within the same hospital)., Results: Among 2 902 756 patients who had surgery, 1 287 845 (44.4%) had operations done by surgeons of the same gender (1 201 712 (41.4%) male patient and male surgeon, 86 133 (3.0%) female patient and female surgeon) and 1 614 911 (55.6%) were by surgeons of different gender (52 944 (1.8%) male patient and female surgeon, 1 561 967 (53.8%) female patient and male surgeon). Adjusted 30 day mortality after surgery was 2.0% for male patient-male surgeon dyads, 1.7% for male patient-female surgeon dyads, 1.5% for female patient-male surgeon dyads, and 1.3% for female patient-female surgeon dyads. Patient-surgeon gender concordance was associated with a slightly lower mortality for female patients (adjusted risk difference -0.2 percentage point (95% confidence interval -0.3 to -0.1); P<0.001), but a higher mortality for male patients (0.3 (0.2 to 0.5); P<0.001) for elective procedures, although the difference was small and not clinically meaningful. No evidence suggests that operative mortality differed by patient-surgeon gender concordance for non-elective procedures., Conclusions: Post-operative mortality rates were similar (ie, the difference was small and not clinically meaningful) among the four types of patient-surgeon gender dyads., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the National Institute on Minority Health and Health Disparities and Gregory Annenberg Weingarten GRoW @Annenberg for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Antiviral defense in ecdysozoan invertebrates requires Dicer with a helicase domain capable of ATP hydrolysis. But despite well-conserved ATPase motifs, human Dicer is incapable of ATP hydrolysis, consistent with a muted role in antiviral defense. To investigate this enigma, we used ancestral protein reconstruction to resurrect Dicer's helicase in animals and trace the evolutionary trajectory of ATP hydrolysis. Biochemical assays indicated ancient Dicer possessed ATPase function, that like extant invertebrate Dicers, is stimulated by dsRNA. Analyses revealed that dsRNA stimulates ATPase activity by increasing ATP affinity, reflected in Michaelis constants. Deuterostome Dicer-1 ancestor, while exhibiting lower dsRNA affinity, retained some ATPase activity; importantly, ATPase activity was undetectable in the vertebrate Dicer-1 ancestor, which had even lower dsRNA affinity. Reverting residues in the ATP hydrolysis pocket was insufficient to rescue hydrolysis, but additional substitutions distant from the pocket rescued vertebrate Dicer-1's ATPase function. Our work suggests Dicer lost ATPase function in the vertebrate ancestor due to loss of ATP affinity, involving motifs distant from the active site, important for coupling dsRNA binding to the active conformation. By competing with Dicer for viral dsRNA, RIG-I-like receptors important for interferon signaling may have allowed or actively caused loss of ATPase function., Competing Interests: AA, PA, BK, BB No competing interests declared, (© 2023, Aderounmu et al.)

The foundational principles of surgical training in the USA are based on didactic education, structured skill training, and experiential learning in surgical patient care with the supervision of surgical faculty. A consortium of professional organizations, academic institutions, and teaching hospitals with surgical faculty provide the structural framework, policies, and curriculum to train and evaluate surgeons capable of independent practice. This manuscript describes the roles of the organizations responsible for surgical training in the USA and highlights areas in evolution in the modern surgical education landscape., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© Association of Surgeons of India 2021.)

Competing Interests: The author reports no conflicts of interest.

Background: The Phase 1 ACS/APDS skills curriculum standardizes intern training. Despite this, institutional implementation varies and is nationally low. We aimed to use Kern's six-steps to tailor this to our program, providing a framework to improve implementation., Methods: Problem identification and general needs assessment were performed. Targeted needs assessment (TNA) of incoming interns ('interns'), current residents, and attendings determined perceived importance of skills and intern's previous experience and confidence. Educational strategies were developed. Learner knowledge was assessed before and after modules, deficiencies identified enabled employment of active learning strategies. Modular and curricular evaluations were completed., Results: TNA determined all interns had been taught knot tying and suturing, and were most confident with suturing, knot tying, and urethral catheterization. Educational strategies included simulation and lectures. Evaluations demonstrated improvement in test scores (pre-v post-) and skills confidence on curricula completion., Conclusion: Our framework utilizes institutional resources and expertise while focusing on determining existing knowledge, skill, and technical deficiencies of learners. This approach demonstrated improvement in knowledge and confidence, and could improve implementation rates of the Phase 1 curriculum., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Effective surgeon educators likely help medical students develop competency and may inspire pursuit of surgical training. We sought to determine the qualities medical students believe embody effective surgical educators., Methods: Mixed-methods study of nationally electronically recruited 3rd-year medical students using virtual semi-structured interviews and anonymous quantitative survey to determine the most critical and most frequently encountered qualities of effective surgical educators. Thematic analysis using grounded theory was undertaken., Results: Data saturation occurred after 9 interviews. Themes of effective surgical educators included: engagement (acknowledging student, knowing their name, talking to the student), fostering a positive learning environment (non-threatening, non-shaming questioning), inclusion (giving responsibility/appropriate autonomy), and understanding how to teach a novice (teaching the student how to learn, adapt to learner). On quantitative analysis of Likert based survey, encouraging, promoting a positive learning climate, timely constructive feedback, and questioning were ranked as most critical., Conclusion: Students highly value positive learning climate and inclusion. Faculty Development to promote these traits may improve clerkship learning and experience., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Optimal nutrition is challenging for patients with gastric and gastroesophageal adenocarcinoma and often requires feeding tube placement prior to preoperative therapy. Feeding jejunostomy (FJ) placement via mini-laparotomy is technically easier to perform than laparoscopic FJ. The purpose of this study was to compare outcomes in patients with gastric adenocarcinoma undergoing laparoscopic versus mini-laparotomy FJ placement., Methods: A retrospective cohort study was performed of patients with gastric adenocarcinoma receiving laparoscopic versus mini-laparotomy FJ at a single tertiary referral center from 2000 to 2018. 30-day outcomes included complications, conversion to laparotomy, reoperation, length of stay, and readmission., Results: A total of 656 patients met the inclusion criteria and were studied. The majority of patients were male (68.1%) with a mean age of 60.6 years. The difference in surgical approach remained relatively stable over time. Overall, 82 (12.5%) patients experienced complications, and three (0.5%) patients died postoperatively. While readmission and conversion to open laparotomy did not differ between groups, overall complications (10.5% vs. 20.8%, p = 0.002), Clavien-Dindo ≥ 3 complications (4.0% vs. 8.9%, p = 0.021), length of stay (4.1 vs. 5.6 days, p < 0.001), and reoperation (0.9% vs. 4.0%, p = 0.002) favored the laparoscopic over mini-laparotomy group., Conclusion: The current study helps clarify the risk of FJ placement in patients with gastric adenocarcinoma requiring nutritional support. Laparoscopic FJ placement has lower overall morbidity and length of stay compared to mini-laparotomy. However, caution is needed in preventing and identifying the rare causes of postoperative mortality that may be associated with laparoscopic FJ placement., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time., Design: We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications., Setting: The ACS-NSQIP database., Participants: Patients undergoing one of 7 emergency general surgery operations., Results: Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality., Conclusion: Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes., Competing Interests: DECLARATION OF COMPETING INTEREST None., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Dicer-2 cleaves double-stranded RNA into siRNAs in a terminus-dependent manner as part of D. melanogaster 's RNA interference pathway. Using ultrafast fluorescence, we probe the local environment of chromophores at the dsRNA terminus upon binding by Dicer-2 and interrogate the effects of Loquacious-PD, an accessory protein. We find substrate-selective modes of molecular recognition that distinguish between blunt and 3'overhang termini, but whose differences are greatly reduced by Loquacious-PD. These results connect the molecular recognition properties of Dicer-2 to its selective processing of dsRNAs with different termini and to its need for Loquacious-PD to efficiently produce endogenous siRNAs.

Objective: Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety., Design: This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training., Conclusions: Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients play a crucial role in surgical training, but little is known about the public's knowledge of general surgery training structure or opinion of resident assessment. Our aim was to evaluate the public's knowledge of general surgery training and assessment processes., Methods: We administered an anonymous, electronic survey to US adult panelists using SurveyGizmo. We used Dillman's Tailored Design Method to optimize response rate. Questions pertained to demographics, knowledge of general surgery training structure, and opinions regarding resident assessment. Outcome measures included public knowledge of the structure of general surgery residency and the perceptions of resident assessment. Univariate and multivariate statistics were used as appropriate., Results: Survey response rate was 93% (2005 of 2148). Respondents had nationally representative demographics. Most respondents had health insurance (87%). Sixty-one percent of respondents believed that 100% of hospitals trained residents. Age <40 years, Black race (odds ratio 1.48 [95% confidence interval (CI) 1.11-1.96]), working in a hospital/health care field (odds ratio 1.49 [95% CI 1.12-1.97]), and having a family member/close acquaintance working in a hospital/health care field (odds ratio 1.53 [95% CI .20-1.94]) were associated with this belief. There was a preference to obtain online information about medical training (30% television [TV] shows, 24% Internet searches, 5% social media). Eighty percent of respondents felt that resident self-assessment and patient assessment of residents was "important" or "essential" when considering readiness for independent practice., Conclusion: The US public has limited knowledge of general surgery training and competency assessment. Public educational strategies may help inform patients about the structure of training and assessment of trainees to improve engagement of these important stakeholders in surgical training., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Some RIG-I-like receptors (RLRs) discriminate viral and cellular dsRNA by their termini, and Drosophila melanogaster Dicer-2 (dmDcr-2) differentially processes dsRNA with blunt or 2 nucleotide 3'-overhanging termini. We investigated the transient kinetic mechanism of the dmDcr-2 reaction using a rapid reaction stopped-flow technique and time-resolved fluorescence spectroscopy. Indeed, we found that ATP binding to dmDcr-2's helicase domain impacts association and dissociation kinetics of dsRNA in a termini-dependent manner, revealing termini-dependent discrimination of dsRNA on a biologically relevant time scale (seconds). ATP hydrolysis promotes transient unwinding of dsRNA termini followed by slow rewinding, and directional translocation of the enzyme to the cleavage site. Time-resolved fluorescence anisotropy reveals a nucleotide-dependent modulation in conformational fluctuations (nanoseconds) of the helicase and Platform-PAZ domains that is correlated with termini-dependent dsRNA cleavage. Our study offers a kinetic framework for comparison to other Dicers, as well as all members of the RLRs involved in innate immunity., Competing Interests: RS, MJ, EL, NR, RN, BB No competing interests declared, (© 2021, Singh et al.)

Background: Effective surgical educators have specific attributes and learner-relationships. Our aim was to determine how intrinsic learning preferences and teaching styles affect surgical educator effectiveness., Methods: We determined i) learning preferences ii) teaching styles and iii) self-assessment of teaching skills for all general surgery attendings. All general surgical residents in our program completed teaching evaluations of attendings., Results: Multimodal was the most common learning preference (20/28). Although the multimodal learning preference appears to be associated with more effective educators than kinesthetic learning preferences, the difference was not statistically significant (80.0% versus 66.7%, p = 0.43). Attendings with Teaching Style 5 were more likely to have a lower "professional attitude towards residents" score on SETQ assessment by residents (OR 0.33 (0.11, 0.96), p = 0.04). Attendings rated their own "communication of goals" (p < 0.001), "evaluation of residents" (p = 0.04) and "overall teaching performance" (p = 0.01) per STEQ domains as significantly lower than the resident's assessment of these cofactors., Conclusion: Identification of factors intrinsic to surgical educators with high effectiveness is important for faculty development. Completion of a teaching style self-assessment by attendings could improve effectiveness., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: The author declares no conflicts of interest.

Background: Despite patients being important stakeholders in surgical training, little is known about the public's perception of trainee participation in surgical care. This study evaluates the public's perception of surgical resident autonomy and supervision., Study Design: An anonymous electronic survey was sent to adult panelists older than 18 years in the US using SurveyGizmo. The design of the survey used Dillman's Tailored Design Method to optimize response rate. Participants completed surveys including demographic characteristics and perceptions toward general surgery resident autonomy. Univariable and multivariable analyses were used as appropriate., Results: Survey response rate was 93% (2,005 of 2,148). Demographic characteristics including age, gender, race or ethnicity, and highest level of education were nationally representative. Most respondents (87%) had health insurance. On multivariable logistic regression analysis, factors associated with participants who would never allow a resident to perform any portion of the operation include: female gender (odds ratio [OR] 1.58; 95% CI, 1.28 to 1.95), no health insurance (OR 1.38; 95% CI, 1.03 to 1.84), Black race (OR 1.82; 95% CI, 1.38 to 2.41), and Hispanic ethnicity (OR 1.49; 95% CI, 1.03 to 2.15). Participants who were younger than 50 years (OR 1.57; 95% CI, 1.24 to 1.98), male (OR 1.90; 95% CI, 1.56 to 2.32), of Black race (OR 1.45; 95% CI, 0.10 to 1.91), Hispanic ethnicity (OR 1.49; 95% CI, 1.05 to 2.11), working in healthcare (OR 2.18; 95% CI, 1.67 to 2.86), or insured (OR 1.46; 95% CI, 1.07 to 1.99) were more likely to believe that resident involvement increases complications., Conclusions: Among survey participants broadly representing the US population, resident participation in operations is not universally accepted. Public perception of surgical resident autonomy and supervision is important, as GME continues to evolve to address readiness for independent practice., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

In vitro, Drosophila melanogaster Dicer-2 (Dcr-2) uses its helicase domain to initiate processing of dsRNA with blunt (BLT) termini, and its Platform•PAZ domain to initiate processing of dsRNA with 3' overhangs (ovrs). To understand the relationship of these in vitro observations to roles of Dcr-2 in vivo, we compared in vitro effects of two helicase mutations to their impact on production of endogenous and viral siRNAs in flies. Consistent with the importance of the helicase domain in processing BLT dsRNA, both point mutations eliminated processing of BLT, but not 3'ovr, dsRNA in vitro. However, the mutations had different effects in vivo. A point mutation in the Walker A motif of the Hel1 subdomain, G31R, largely eliminated production of siRNAs in vivo, while F225G, located in the Hel2 subdomain, showed reduced levels of endogenous siRNAs, but did not significantly affect virus-derived siRNAs. In vitro assays monitoring dsRNA cleavage, dsRNA binding, ATP hydrolysis, and binding of the accessory factor Loquacious-PD provided insight into the different effects of the mutations on processing of different sources of dsRNA in flies. Our in vitro studies suggest effects of the mutations in vivo relate to their effects on ATPase activity, dsRNA binding, and interactions with Loquacious-PD. Our studies emphasize the importance of future studies to characterize dsRNA termini as they exist in Drosophila and other animals., (© 2020 Donelick et al.; Published by Cold Spring Harbor Laboratory Press for the RNA Society.)

Objective: The current, unprecedented pace of change in medicine challenges healthcare professionals to stay up-to-date. To more effectively disseminate new surgical or endoscopic techniques a modern paradigm of training is required. Our aim was to develop a curricular framework for complex techniques that provide logistical challenges to training in order to increase safe, effective use. We use colonic endoscopic submucosal dissection (cESD) as an example., Design: Curriculum development followed a multistep process representing best practice in training and education. First, a Clinical Needs Assessment established the demand for/sustainability of training. A Training Needs Analysis then identified the knowledge, skills, and attitudes required to perform cESD. A modified Delphi process defined desired learner characteristics, identified indications/contraindications to cESD, and developed a procedural task list. A pilot simulation program gathered feedback from cESD faculty experts and learners. Finally, a Behavioral Observation Scale was developed as a clinical assessment tool to assess procedural performance., Setting: The Houston Methodist Institute for Technology, Innovation and Education., Participants: The first Curriculum Design Summit engaged 11 clinical SMEs, 4 education and training SMEs, 3 market development SMEs, and 1 medical device research and design engineer. The second Curriculum Design Summit engaged 10 clinical SMEs, 4 education and training SMEs, and 4 market development SMEs. We also engaged 12 Learner SMEs at both hands-on pilot courses who currently are training to perform cESD., Results: Desired learner criteria were defined (e.g., in practice >2 years, available case volume ≥25/year) to ensure ability and motivation of learners. Lesions were classified by (1) suitability for cESD (Clinical T1N0M0, Paris 0-IIa +1s  > 2 cm, 0-IIc + IIa, 0-IIc), and (2) suitability for trainee experience level. A comprehensive cESD task list was constructed and an assessment tool created based on SME review of key characteristics (e.g., comprehensiveness and usability)., Conclusion: We describe a comprehensive framework to develop educational curricula for complex surgical/endoscopic techniques with logistical challenges. To illustrate the sustainability of this training model and impact on patient outcomes, we plan to further develop and implement this program nationally., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons/Association of Program Directors in Surgery operative skills curriculum standardizes training. However, simulation resources are variable with curriculum implementation institution dependent. Our aim was to use Kern's six steps of curricular development to demonstrate how to tailor the American College of Surgeons/Association of Program Directors in Surgery Phase 2 curriculum to program specific needs., Methods: Problem identification and general needs assessment was performed. Targeted needs assessment of general surgery residents and attendings was conducted to determine perceived importance of operative skills and residents' confidence with these skills and attendings perceptions of deficiencies in technical skills using the Objective Structured Assessment of Technical Skills criteria. Educational strategies were developed dependent on program resources. The program was piloted between 2018 to 2019 and implemented in the 2019 to 2020 academic year. Assessment of resident technical skills and resident or faculty teaching skills was performed for each session. Resident confidence with procedures was assessed using the Zwisch scale before and after modules. Curricular evaluations were completed by residents after each module., Results: The previous curriculum did not comprehensively cover Phase 2 modules and was not tailored to the needs of residents. Targeted needs assessment revealed differences in prioritization of learning for techniques by seniority (most important operation for faculty: laparoscopic cholecystectomy, postgraduate year 4 and 5: laparoscopic partial colectomy, interns: open inguinal/femoral hernia repair). Faculty identified technical skills on which to focus (ie, interns' knowledge of a specific procedure, postgraduate year 4 and 5 flow of the operation and forward planning). Educational strategies employed included wet and dry lab simulations and online materials. Residents reported increased procedural confidence after curriculum completion., Conclusion: This comprehensive implementation of the American College of Surgeons/Association of Program Directors in Surgery Phase 2 skills curriculum effectively used resources and expertise of an institution and focused on the knowledge and technical deficiencies of the target learners. Improvement in learner confidence was demonstrated by this approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Surgical educator effectiveness is valued but lacks an operational definition. Clearly defining attributes consistent with effective surgical educators allows for the development of professional activities directed to nurture these qualities. Our aim was to identify the literature defining qualities of an effective surgical educator, and tools to measure effectiveness., Methods: We searched PubMed, Medline, Scopus and Academic Search Complete for English language articles from 1 July 2009-1 July 2019. Two reviewers screened all abstracts for relevance and read full text of selected articles to identify included studies. Inclusion criteria were description/definition of an effective surgical educator or description of assessment/measurement of effectiveness in surgical educators. Data extracted included: study design, participants, definition/description of qualities of an effective surgical educator, qualitative or quantitative methods to assess surgical educators., Results: Initial search identified 8086 articles. Of these, 2357 articles were excluded as duplicates and 5729 abstracts screened with 5638 excluded due to irrelevance. Full text review was performed for 91 articles to assess eligibility, 23 met inclusion criteria. The majority (74%) did not clearly define an effective surgical educator. Themes from six studies that determined important qualities include: communication, leadership skills, professionalism, respect, positive learning climate, and brief-intraoperative teaching-debrief model. One validated assessment tool was identified., Conclusions: There is little published work defining or assessing effective surgical educators. Establishment of a positive learning climate and excellent communication skills continue to be important qualities that define surgical educator effectiveness.

Background: Effective surgical education is key to resident professional and personal development. There is little literature defining or assessing effective surgical educators and no common definition of effectiveness in use. The opinion of surgical residents has never been qualitatively studied. Our aim was to determine what general surgery residents perceive as qualities of effective surgical educators., Methods: A qualitative and quantitative study of general surgery senior residents (postgraduate year [PGY]-4 and -5) at a single tertiary academic institution was performed. In-depth semistructured interviews were conducted with all senior residents to determine the overall opinion of effective educators. Thematic analysis was performed using grounded theory. Participants completed a Likert-based survey to determine which qualities of an effective educator were (1) most critical and (2) had been most commonly encountered during training. Institutional review board approval was obtained., Results: Data saturation occurred after 13 interviews (7 PGY-4, 6 PGY-5). Interviewees described attitudes, behaviors, and cognitions essential for effective surgical educators. They described important attributes of the trainee-trainer relationship and learning environment. On quantitative analysis, excellent communication, promoting a positive learning climate, timely constructive feedback, and technical expertise were ranked as most critical. Residents most often encountered educators with excellent communication, who fostered a positive learning climate, with clinical and technical expertise, and who provided leadership or mentorship., Conclusion: General surgery residents believe effective educators recognize the importance of communication and a positive learning environment, are able to adapt to the learner or environment, have clinical and technical expertise, and form a bond with their learner. This framework can inform faculty development programs to improve surgical education., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The number of mobile-applications (Apps) increases daily. The regulation of App content is minimal yet surgical residents use these in daily educational practice. Surgical educators must be aware of the quality, efficacy, and validity of Apps available to effectively educate residents. The aim of this review was to determine the quality, efficacy, and validity evidence for educational Apps used by surgical residents., Materials and Methods: We searched PubMed, Embase, and ERIC for articles published before September 1, 2019. Controlled vocabulary and natural language describing Apps/surgical residents were used. Two reviewers evaluated abstracts for inclusion., Inclusion Criteria: studies measuring the quality, efficacy, or validity of educational Apps for surgical residents. Data was extracted from full text of included articles: study design, participants, App investigated, App development, evidence for efficacy, or validity of App., Results: Initial search identified 278 articles. 64 articles were duplicates and 214 articles were screened. A further 156 were excluded with 58 full text articles assessed for eligibility. Forty-five were included in analysis. Simulation (9/45) and Feedback (15/45) Apps were the most commonly studied in surgical residents. These were the main Apps that provided validity evidence for their use in education., Conclusion: Surgical education is evolving as educational technology becomes more prevalent. To be effective as surgical educators we must understand and appropriately use available tools. Of the educational Apps studied (21 Apps in 8 categories), only 3 categories reported validity evidence. Future studies should take care to measure validity and efficacy of educational Apps for surgical education to ensure quality control., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors have no conflicts of interests to disclose.

Background: Our objective was to identify perceptions of the environment for women in surgery among 4 academic institutions., Methods: Faculty surgeons and senior surgery residents were randomly selected to participate in a parallel study with concurrent quantitative and qualitative data collection. Outcomes were perceptions of the environment for women in surgery. Measures included semi-structured interviews, survey responses, and responses to scenarios., Results: Saturation was achieved after 36 individuals were interviewed: 14 female (8 faculty, 6 residents) and 22 male (18 faculty, 4 residents) surgeons. Men (100%) and women (86%) reported gender disparity in surgery and identified 6 major categories which influence disparity: definitions of gender disparity, gaps in mentoring, family responsibility, disparity in leave, unequal pay, and professional advancement. Overall 94% of participants expressed concerns with gaps in mentoring, but 64% of women versus 14% of men reported difficulties finding role models who faced similar obstacles. Over half (53%) reported time with loved ones as their biggest sacrifice to advance professionally. Both female and male respondents expressed system-based biases favoring individuals willing to sacrifice family. A global subconscious bias against the expectations, abilities, and goals of female surgeons were perceived to impede promotion and advancement., Conclusion: Both female and male surgeons report substantial gender-based barriers in surgery for women. Despite improvements, fundamental issues such as lack of senior role models, limited support for surgeons with families, and disparities in hiring and promotion persist. This is an opportunity to make substantive changes to the system and eliminate barriers for women joining surgery, advancing their careers, and achieving their goals in a timely fashion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The DUX4 transcription factor is normally expressed in the cleavage-stage embryo and regulates genes involved in embryonic genome activation. Misexpression of DUX4 in skeletal muscle, however, is toxic and causes facioscapulohumeral muscular dystrophy (FSHD). We recently showed DUX4-induced toxicity is due, in part, to the activation of the double-stranded RNA (dsRNA) response pathway and the accumulation of intranuclear dsRNA foci. Here, we determined the composition of DUX4-induced dsRNAs. We found that a subset of DUX4-induced dsRNAs originate from inverted Alu repeats embedded within the introns of DUX4-induced transcripts and from DUX4-induced dsRNA-forming intergenic transcripts enriched for endogenous retroviruses, Alu and LINE-1 elements. However, these repeat classes were also represented in dsRNAs from cells not expressing DUX4. In contrast, pericentric human satellite II (HSATII) repeats formed a class of dsRNA specific to the DUX4 expressing cells. Further investigation revealed that DUX4 can initiate the bidirectional transcription of normally heterochromatin-silenced HSATII repeats. DUX4-induced HSATII RNAs co-localized with DUX4-induced nuclear dsRNA foci and with intranuclear aggregation of EIF4A3 and ADAR1. Finally, gapmer-mediated knockdown of HSATII transcripts depleted DUX4-induced intranuclear ribonucleoprotein aggregates and decreased DUX4-induced cell death, suggesting that HSATII-formed dsRNAs contribute to DUX4 toxicity., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Protein kinase RNA-activated (PKR) is an interferon-inducible kinase that is potently activated by long double-stranded RNA (dsRNA). In a previous study, we found that snoRNAs exhibit increased association with PKR in response to metabolic stress. While it was unclear if snoRNAs also activated PKR in cells, activation in vitro was observed. snoRNAs do not exhibit the double-stranded character typically required for activation of PKR, but some studies suggest such RNAs can activate PKR if triphosphorylated at the 5' terminus, or if they are able to form intermolecular dimers. To interrogate the mechanism of PKR activation by snoRNAs in vitro we focused on SNORD113. Using multiple methods for defining the 5'-phosphorylation state, we find that activation of PKR by SNORD113 does not require a 5'-triphosphate. Gel purification from a native gel followed by analysis using analytical ultracentrifugation showed that dimerization was also not responsible for activation. We isolated distinct conformers of SNORD113 from a native polyacrylamide gel and tracked the activating species to dsRNA formed from antisense RNA synthesized during in vitro transcription with T7 RNA polymerase. Similar studies with additional snoRNAs and small RNAs showed the generality of our results. Our studies suggest that a 5' triphosphate is not an activating ligand for PKR, and emphasize the insidious nature of antisense contamination., (© 2019 Safran et al.; Published by Cold Spring Harbor Laboratory Press for the RNA Society.)

Surgeons around the globe are challenged by the rapid evolution of the environment in which they practice their profession. Changes in surgical technologies, the complexity of surgical patient care, and the regulatory and financial environment of surgical care delivery demand that surgeons be supported in their work with access to superb educational offerings and engagement to foster satisfaction and efficacy in their professional activities. The American College of Surgeons (ACS), the largest international surgical professional organization, is committed to supporting surgeons as leaders in the healthcare system to build programs to create the optimal environment for delivery of quality surgical care to our patients. A selected portfolio of the programs of the ACS is presented., (©2019 Bass B.L., published by De Gruyter, Berlin/Boston.)

Long double-stranded RNAs (dsRNAs) are abundantly expressed in animals, in which they frequently occur in introns and 3' untranslated regions of mRNAs. Functions of long, cellular dsRNAs are poorly understood, although deficiencies in adenosine deaminases that act on RNA, or ADARs, promote their recognition as viral dsRNA and an aberrant immune response. Diverse dsRNA-binding proteins bind cellular dsRNAs, hinting at additional roles. Understanding these roles is facilitated by mapping the genomic locations that express dsRNA in various tissues and organisms. ADAR editing provides a signature of dsRNA structure in cellular transcripts. In this review, we detail approaches to map ADAR editing sites and dsRNAs genome-wide, with particular focus on high-throughput sequencing methods and considerations for their successful application to the detection of editing sites and dsRNAs., (Copyright © 2019 Cold Spring Harbor Laboratory Press; all rights reserved.)

Background: Telemedicine is an emerging medium for the delivery of ambulatory care, but the reimbursement profile of telemedicine visits in the surgical setting has not been well studied., Methods: A retrospective assessment of telemedicine encounters for thyroid and parathyroid conditions occurring from April 2015 to April 2017 was performed. Financial reimbursement from commercial payers for new and established patient visits were compared between telemedicine visits and in-person visits. Patient "savings" in terms of travel distance and drive time were calculated., Results: A total of 290 telemedicine encounters were conducted; 7% were initial consultations, 47% were postoperative visits, and 45% were follow-up visits. The median patient age was 57 years. The median round-trip travel distance saved was 123.6 miles with estimated drive time of 2.4 hours per encounter. In 2% of cases, a second in-person visit within the 90-day global period occurred after a postoperative telemedicine encounter. Charges were filed for 67 encounters. The initial unpaid claims rate was 6%, which was consistent with the unpaid claims rate for in-person visits. The charge-to-collection ratio was comparable to that of in-person visits. There was a higher ratio of level 2 visits in the telemedicine encounters. Over the study period, 70 clinic hours were liberated via the use of telemedicine., Conclusion: Endocrine surgery telemedicine visits have the same level for level reimbursement profile as in-person visits. Down-coding and elimination of components of in-office physical examinations may lead to modest decreases in overall reimbursement. Other advantages include reallocation of clinic resources and decreased travel burden for patients., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The function of Dicer's helicase domain has been enigmatic since its discovery. Why do only some Dicers require ATP, despite a high degree of sequence conservation in their helicase domains? We discuss evolutionary considerations based on differences between vertebrate and invertebrate antiviral defense, and how the helicase domain has been co-opted in extant organisms as the binding site for accessory proteins. Many accessory proteins are double-stranded RNA binding proteins, and we propose models for how they modulate Dicer function and catalysis., (© 2019 Hansen et al.; Published by Cold Spring Harbor Laboratory Press.)

Complementary sequences in cellular transcripts base-pair to form double-stranded RNA (dsRNA) structures. Because transposon-derived repeats often give rise to self-complementary sequences, dsRNA structures are prevalent in eukaryotic genomes, typically occurring in gene introns and untranslated regions (UTRs). However, the regulatory impact of double-stranded structures within genes is not fully understood. We used three independent methods to define loci in Caenorhabditis elegans predicted to form dsRNA and correlated these structures with patterns of gene expression, gene essentiality, and genome organization. As previously observed, dsRNA loci are enriched on distal arms of C. elegans autosomes, where genes typically show less conservation and lower overall expression. In contrast, we find that dsRNAs are associated with essential genes on autosome arms, and dsRNA-associated genes exhibit higher-than-expected expression and histone modification patterns associated with transcriptional elongation. Genes with significant repetitive sequence content are also highly expressed, and, thus, observed gene expression trends may relate either to dsRNA structures or to repeat content. Our results raise the possibility that as-yet-undescribed mechanisms promote expression of loci that produce dsRNAs, despite their well-characterized roles in gene silencing., (© 2018 Reich and Bass; Published by Cold Spring Harbor Laboratory Press for the RNA Society.)

Objective: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery., Summary of Background Data: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion., Methods: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper., Results: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals., Conclusion: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition-doing good for our patients.

Background: Despite rapid growth of the scientific literature, no consensus guidelines have emerged to define the optimal criteria for editors to grade submitted manuscripts. The purpose of this project was to assess the peer reviewer metrics currently used in the surgical literature to evaluate original manuscript submissions., Methods: Manuscript grading forms for 14 of the highest circulation general surgery-related journals were evaluated for content, including the type and number of quantitative and qualitative questions asked of peer reviewers. Reviewer grading forms for the seven surgical journals with the higher impact factors were compared to the seven surgical journals with lower impact factors using Fisher's exact tests., Results: Impact factors of the studied journals ranged from 1.73 to 8.57, with a median impact factor of 4.26 in the higher group and 2.81 in the lower group. The content of the grading forms was found to vary considerably. Relatively few journals asked reviewers to grade specific components of a manuscript. Higher impact factor journal manuscript grading forms more frequently addressed statistical analysis, ethical considerations, and conflict of interest. In contrast, lower impact factor journals more commonly requested reviewers to make qualitative assessments of novelty/originality, scientific validity, and scientific importance., Conclusion: Substantial variation exists in the grading criteria used to evaluate original manuscripts submitted to the surgical literature for peer review, with differential emphasis placed on certain criteria correlated to journal impact factors., Competing Interests: Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Metabolic syndrome (MetS) entails the simultaneous presence of a constellation of dangerous risk factors including obesity, diabetes, hypertension, and dyslipidemia. The prevalence of MetS in Western society continues to rise and implies an elevated risk for surgical complications and/or poor surgical outcomes within the affected population., Objective: To assess the risks and outcomes of multi-morbid patients with MetS undergoing open ventral hernia repair., Setting: Multi-institutional case-control study in the United States., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was sampled for patients undergoing initial open ventral hernia repair from 2012 through 2014 and then stratified into 2 cohorts based on the presence or absence of MetS. Statistical analyses were performed to evaluate preoperative co-morbidities, intraoperative details, and postoperative morbidity and mortality to identify risk factors for adverse outcomes., Results: Mean age (61.0 versus 56.0 yr, P<.001), body mass index (39.2 versus 31.1, P<.001), and prevalence of co-morbidities of multiple organ systems were significantly higher (P<.001) in the MetS cohort compared to control. Patients with MetS received higher American Society of Anesthesiologists classifications (81.0% versus 43.1% class 3 or higher, P<.001), were more likely to require operation as emergency cases (11.4% versus 7.2%, P<.001), required longer operative times (103 versus 87 min, P<.001), had longer hospitalizations (3.5 versus 2.4 d, P<.001), and had more contaminated wounds (15.9% versus 12.0% class 2 or higher, P<.001). Overall, they had more medical (7.5% versus 4.2%, P<.001), and surgical complications (9.7% versus 5.4%, P<.001), experienced more readmissions (8.3% versus 5.7%, P<.001) and reoperations (3.4% versus 2.5%, P<.001), and were at higher risk for eventual death (.8% versus .5%, P=.008)., Conclusions: The presence of MetS is related to a multitude of unfavorable outcomes and increased mortality after open ventral hernia repair compared with a non-MetS control group. MetS is a useful marker for high operative risk in a population that is generally prone to obesity and its associated diseases., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)