Publications by authors named "William Stein"

83 Publications

Safe Use of Erythromycin For Refractory Gastroparesis After Small Bowel Transplantation.

Exp Clin Transplant 2021 Apr 16. Epub 2021 Apr 16.

From the the Intestinal Rehabilitation and Transplant Center, Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Current therapeutic options with prokinetic agents for posttransplant gastroparesis are limited. Erythromycin is associated with adverse reactions, including corrected QT interval prolongation and cytochrome P450 3A4 isoenzyme inhibition. The use of erythromycin has been avoided in patients undergoing treatment with cyclosporine or tacrolimus because of significant fluctuations in therapeutic immunosuppression levels. We report herein the successful use of erythromycin after visceral transplant to treat delayed gastric emptying. Two patients were managed with oral erythromycin (initial dose of 750 mg/d divided into 3 doses) for gastroparesis after visceral transplant. Patient 1 was a woman aged 42 years with a history of chronic intestinal pseudo-obstruction syndrome who underwent isolated small bowel transplant with dual (gastric and duodenal) proximal allograft anastomosis. Posttransplant gastroparesis was initially managed with oral metoclopramide. The patient also required high doses of tacrolimus (36 mg/d) to maintain adequate immunosuppression levels. The decision was made to change metoclopramide to erythromycin, which significantly decreased the daily tacrolimus dose requirement (from 36 to 9 mg/d), with resolution of nausea and intermittent bloating symptoms. Patient 2 was a woman aged 35 years with ultra-short gut syndrome after extensive enterectomy due to intestinal volvulus who underwent uneventful combined intestinal and colon transplant. Conventional pharmacologic therapy for gastroparesis was initiated after surgery without success. Erythromycin was started 15 days posttransplant, with significant improvement in her symptoms, and discontinued 47 days post-transplant. To maintain therapeutic levels (8-10 mg/dL), daily tacrolimus dose was decreased 75.8% and 36.5% for patients 1 and 2, respectively. No significant side effects associated with erythromycin use were observed in either patient. Our findings here suggest that erythromycin may be safely used for gastroparesis after small bowel transplant. Close monitoring of immunosuppressive drug levels and dose adjustments of other medications affected by inhibition of cytochrome P450 3A4 are advised.
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http://dx.doi.org/10.6002/ect.2020.0463DOI Listing
April 2021

Mid-Devonian Archaeopteris Roots Signal Revolutionary Change in Earliest Fossil Forests.

Curr Biol 2020 02 19;30(3):421-431.e2. Epub 2019 Dec 19.

Department of Animal and Plant Sciences, University of Sheffield, Sheffield S10 2TN, UK.

The origin of trees and forests in the Mid Devonian (393-383 Ma) was a turning point in Earth history, marking permanent changes to terrestrial ecology, geochemical cycles, atmospheric CO levels, and climate. However, how all these factors interrelate remains largely unknown. From a fossil soil (palaeosol) in the Catskill region near Cairo NY, USA, we report evidence of the oldest forest (mid Givetian) yet identified worldwide. Similar to the famous site at Gilboa, NY, we find treefern-like Eospermatopteris (Cladoxylopsida). However, the environment at Cairo appears to have been periodically drier. Along with a single enigmatic root system potentially belonging to a very early rhizomorphic lycopsid, we see spectacularly extensive root systems here assigned to the lignophyte group containing the genus Archaeopteris. This group appears pivotal to the subsequent evolutionary history of forests due to possession of multiple advanced features and likely relationship to subsequently dominant seed plants. Here we show that Archaeopteris had a highly advanced root system essentially comparable to modern seed plants. This suggests a unique ecological role for the group involving greatly expanded energy and resource utilization, with consequent influence on global processes much greater than expected from tree size or rooting depth alone.
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http://dx.doi.org/10.1016/j.cub.2019.11.067DOI Listing
February 2020

Global priorities for conserving the evolutionary history of sharks, rays and chimaeras.

Nat Ecol Evol 2018 02 18;2(2):288-298. Epub 2018 Jan 18.

Department of Biological Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.

In an era of accelerated biodiversity loss and limited conservation resources, systematic prioritization of species and places is essential. In terrestrial vertebrates, evolutionary distinctness has been used to identify species and locations that embody the greatest share of evolutionary history. We estimate evolutionary distinctness for a large marine vertebrate radiation on a dated taxon-complete tree for all 1,192 chondrichthyan fishes (sharks, rays and chimaeras) by augmenting a new 610-species molecular phylogeny using taxonomic constraints. Chondrichthyans are by far the most evolutionarily distinct of all major radiations of jawed vertebrates-the average species embodies 26 million years of unique evolutionary history. With this metric, we identify 21 countries with the highest richness, endemism and evolutionary distinctness of threatened species as targets for conservation prioritization. On average, threatened chondrichthyans are more evolutionarily distinct-further motivating improved conservation, fisheries management and trade regulation to avoid significant pruning of the chondrichthyan tree of life.
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http://dx.doi.org/10.1038/s41559-017-0448-4DOI Listing
February 2018

Unique growth strategy in the Earth's first trees revealed in silicified fossil trunks from China.

Proc Natl Acad Sci U S A 2017 11 23;114(45):12009-12014. Epub 2017 Oct 23.

State Key Laboratory of Palaeobiology and Stratigraphy, Nanjing Institute of Geology and Palaeontology, Chinese Academy of Sciences, Nanjing 210008, China.

Cladoxylopsida included the earliest large trees that formed critical components of globally transformative pioneering forest ecosystems in the Mid- and early Late Devonian (ca. 393-372 Ma). Well-known cladoxylopsid fossils include the up to ∼1-m-diameter sandstone casts known as from Middle Devonian strata of New York State. Cladoxylopsid trunk structure comprised a more-or-less distinct cylinder of numerous separate cauline xylem strands connected internally with a network of medullary xylem strands and, near the base, externally with downward-growing roots, all embedded within parenchyma. However, the means by which this complex vascular system was able to grow to a large diameter is unknown. We demonstrate-based on exceptional, up to ∼70-cm-diameter silicified fossil trunks with extensive preservation of cellular anatomy from the early Late Devonian (Frasnian, ca. 374 Ma) of Xinjiang, China-that trunk expansion is associated with a cylindrical zone of diffuse secondary growth within ground and cortical parenchyma and with production of a large amount of wood containing both rays and growth increments concentrically around individual xylem strands by normal cambia. The xylem system accommodates expansion by tearing of individual strand interconnections during secondary development. This mode of growth seems indeterminate, capable of producing trees of large size and, despite some unique features, invites comparison with secondary development in some living monocots. Understanding the structure and growth of cladoxylopsids informs analysis of canopy competition within early forests with the potential to drive global processes.
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http://dx.doi.org/10.1073/pnas.1708241114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692553PMC
November 2017

Surgical and medical approach to patients requiring total small bowel resection: Managing the "no gut syndrome".

Surgery 2017 10 26;162(4):871-879. Epub 2017 Jul 26.

Intestinal Rehabilitation and Transplant Center, Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Background: Total resection of the jejunum and ileum, a rarely performed procedure, is indicated after mesenteric vascular events, trauma, or resection of abdominal neoplasms. We describe our recent experience with the operative and medical management of patients with "no gut syndrome."

Methods: We retrospectively reviewed 341 adult patients who were referred to our center between January 2013 and December 2016.

Results: Thirteen patients with a mean age of 42.5 years (range 17 to 66 years) underwent near total enterectomy. Indications for small bowel resection were vascular event (n = 5), intraabdominal fibroid/desmoid (n = 4), and trauma (n = 4). Foregut secretions were managed with duodenocolostomy (n = 5), tube decompression (n = 5), and end duodenostomy (n = 2). Duodenal stump was stapled off in 4 cases. One patient underwent a spleen-preserving duodenopancreatectomy combined with total enterectomy. Biliary secretions were managed with choledochocolostomy. All patients were discharged on full total parenteral nutrition infused over a 10- to 16-hour period. Average total parenteral nutrition volume and caloric requirement were 2,800 mL/day (range 2,000 to 4,000) and 1,774 Kcal/day (range 1,443 to 2,290), respectively. Patients who underwent duodenocolonic anastomosis received smaller TPN volume (33.8 vs 49.8 mL/kg). Ten patients (77%) required supplemental intravenous fluid. There were no intraoperative or perioperative deaths. One patient was lost to follow-up 2 months after operation. After a 20-month median follow-up (range 4 to 48 months), 9 patients are still alive (75%). All patients with duodenocolostomy remain alive (median follow-up 36.4 months). Three patients underwent uneventful isolated small bowel transplantation, and another 4 are being evaluated or are already listed for visceral transplantation.

Conclusion: In summary, resection of the entire small bowel is feasible and can be a lifesaving procedure for a select group of patients. Long-term survival can be achieved in specialized centers. In addition, reestablishment of gastrointestinal tract continuity after total enterectomy appears to be the best option for postoperative fluid and electrolyte management.
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http://dx.doi.org/10.1016/j.surg.2017.05.012DOI Listing
October 2017

Are There Gaps in Current Thoracic Surgery Residency Training Programs?

Ann Thorac Surg 2016 Jun 13;101(6):2350-5. Epub 2016 Apr 13.

Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Background: Cardiothoracic surgery is rapidly evolving to adapt to a changing health care environment and a wider application of innovative techniques. The Society of Thoracic Surgeons Workforce on Thoracic Surgery Resident Issues Transition to Practice Task Force sought to identify new or existing gaps of training in contemporary thoracic surgery residency training programs.

Methods: A voluntary survey consisting of 24 questions was distributed to recent graduates of thoracic surgery residency programs in the United States during the 2014 American Board of Thoracic Surgery oral examination application process. Fifty-five of 132 applicants anonymously participated.

Results: The majority of respondents admitted that they needed more instruction or lacked confidence with the following specific cardiothoracic procedures: minimally invasive cardiac operations (25/52, 48%), robotic cardiac operations (29/52, 55.8%), endovascular operations (28/52, 53.8%), robotic pulmonary operations (29/52, 55.8%), minimally invasive esophageal operations (24/52, 46.2%), robotic esophageal operations (32/52, 61.5%), and operations on congenital cardiac conditions (31/52, 59.6%). The respondents further declared either a need for more instruction or lack of confidence in employment contracting (17/21, 81.0%), negotiating terms of employment (17/21, 81.0%), and professional service agreements (16/21, 76.2%).

Conclusions: Further exposure to minimally invasive robotic procedures, operations on congenital conditions, and issues of practice management appear to be needed in contemporary cardiothoracic training in the United States. These identified gaps may assist cardiothoracic surgery residency programs to optimally prepare future graduates for our evolving specialty.
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http://dx.doi.org/10.1016/j.athoracsur.2016.01.038DOI Listing
June 2016

The Compleat Editor.

Northwest Dent 2015 Nov-Dec;94(6):13-7

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February 2016

Behold, Winter Comes.

Authors:
William E Stein

Northwest Dent 2015 Nov-Dec;94(6):11

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February 2016

Repetitive patterns in rapid optical variations in the nearby black-hole binary V404 Cygni.

Nature 2016 Jan;529(7584):54-8

Crimean Astrophysical Observatory, 298409 Nauchny, Crimea.

How black holes accrete surrounding matter is a fundamental yet unsolved question in astrophysics. It is generally believed that matter is absorbed into black holes via accretion disks, the state of which depends primarily on the mass-accretion rate. When this rate approaches the critical rate (the Eddington limit), thermal instability is supposed to occur in the inner disk, causing repetitive patterns of large-amplitude X-ray variability (oscillations) on timescales of minutes to hours. In fact, such oscillations have been observed only in sources with a high mass-accretion rate, such as GRS 1915+105 (refs 2, 3). These large-amplitude, relatively slow timescale, phenomena are thought to have physical origins distinct from those of X-ray or optical variations with small amplitudes and fast timescales (less than about 10 seconds) often observed in other black-hole binaries-for example, XTE J1118+480 (ref. 4) and GX 339-4 (ref. 5). Here we report an extensive multi-colour optical photometric data set of V404 Cygni, an X-ray transient source containing a black hole of nine solar masses (and a companion star) at a distance of 2.4 kiloparsecs (ref. 8). Our data show that optical oscillations on timescales of 100 seconds to 2.5 hours can occur at mass-accretion rates more than ten times lower than previously thought. This suggests that the accretion rate is not the critical parameter for inducing inner-disk instabilities. Instead, we propose that a long orbital period is a key condition for these large-amplitude oscillations, because the outer part of the large disk in binaries with long orbital periods will have surface densities too low to maintain sustained mass accretion to the inner part of the disk. The lack of sustained accretion--not the actual rate--would then be the critical factor causing large-amplitude oscillations in long-period systems.
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http://dx.doi.org/10.1038/nature16452DOI Listing
January 2016

Mercy, Mercy, Mercy.

Authors:
William E Stein

Northwest Dent 2015 Sep-Oct;94(5):11

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December 2015

Heroin: What's Next?

Authors:
William E Stein

Northwest Dent 2015 Jan-Feb;94(1):13

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December 2015

Can We Run Out of Compassion?

Authors:
William E Stein

Northwest Dent 2015 Mar-Apr;94(2)

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December 2015

The Saints Among Us.

Authors:
William E Stein

Northwest Dent 2015 May-Jun;94(3):11

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December 2015

Understanding Why Residents May Inaccurately Log Their Role in Operations: A Look at the 2013 In-Training Examination Survey.

Ann Thorac Surg 2016 Jan 9;101(1):323-8. Epub 2015 Oct 9.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: With increased time and quality pressures, it may be more difficult for residents in cardiothoracic surgery residency programs to get independent operative experience. That may lead residents to inaccurately report their role as "surgeon" to meet American Board of Thoracic Surgery (ABTS) case requirements.

Methods: The 2013 In-Training Examination surveyed 312 cardiothoracic surgery residents and was used to contrast residents in traditional 2-year and 3-year cardiothoracic surgery residencies (traditional, n = 216) with those in 6-year integrated or 3+4-year programs (integrated, n = 96).

Results: Traditional program residents reported a higher percentage of cases that met the ABTS criteria of surgeon than did integrated program residents (p = 0.05) but were less likely to meet requirements if all cases were logged accurately (p = 0.03). The majority of residents in each program believed that their case log accurately reflected their experience as "surgeon." Residents who tended to log cases incorrectly had lower self-reported 2012 In-Training Examination percentiles, were less likely to meet case requirements if logged properly, and felt less prepared for board examinations and eventual practice compared with residents who logged cases correctly (all p < 0.001). Residents who believed they would not meet case requirements if logged correctly cited limited surgical opportunities, poor case diversity, and a compromised training environment but not the 80-hour work week, excessive simulation, or disproportionate number of complex cases as causes.

Conclusions: Overall cardiothoracic surgery residents appear to be satisfied with their training. There were specific subsets of trainees in both traditional and Integrated programs that are misrepresenting their role on cases because they otherwise may not meet the requirements.
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http://dx.doi.org/10.1016/j.athoracsur.2015.07.047DOI Listing
January 2016

Missing a Mentor.

Authors:
William E Stein

Northwest Dent 2015 Jul-Aug;94(4):11

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December 2015

Resident Perception of Technical Skills Education and Preparation for Independent Practice.

Ann Thorac Surg 2015 Dec 26;100(6):2305-12; discussion 2312-3. Epub 2015 Sep 26.

Thoracic Surgery Resident's Association, Executive Committee, Chicago, Illinois; Department of Cardiothoracic and Vascular Surgery, University of Texas at Houston, Houston, Texas.

Background: Surgical skills are traditionally taught and practiced in the operating room. However, changes in health care policy and outcome-based evaluation have decreased trainee operative autonomy. We examined cardiothoracic residents' perceptions of operative experience and the role of simulation.

Methods: The In-Training Examination (ITE) is taken each year by all residents. Completion of a 30-question preexamination survey is mandatory, ensuring a 100% response rate. Survey data related to operative experience, career preparedness, and surgical simulation were analyzed. Opinion questions were asked on a 5-point Likert scale. Respondents were grouped into three cohorts by training paradigm (2-year versus 3-year traditional programs and 6-year integrated programs).

Results: In all, 314 respondents (122 2-year, 96 3-year, and 96 6-year integrated) completed the survey. Of the three groups, residents in 3-year programs had the highest levels of satisfaction. Advanced training was most common among residents in 6-year integrated programs (66%, versus 49% for 2-year and 26% for 3-year programs; p = 0.63). Desire to specialize drove further training (97%), with 2% stating further training was needed owing to inadequacy and 1% owing to a poor job market. In all assessed categories, the majority of residents believed that simulation did not completely replicate the educational value of an operative case.

Conclusions: Cardiothoracic residents largely feel well prepared for the transition to practice under the current educational paradigm. Although many residents seek advanced training, it seems driven by the desire for specialization. Residents view simulation as an adjunct to traditional intraoperative education, but not as a viable replacement. Further study is necessary to better understand how best to integrate simulation with operative experience.
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http://dx.doi.org/10.1016/j.athoracsur.2015.05.135DOI Listing
December 2015

A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014.

Ann Thorac Surg 2015 Oct 11;100(4):1305-13; discussion 1313-4. Epub 2015 Jul 11.

Department of Cardiothoracic and Vascular Surgery, University of Texas Memorial Hermann-Texas Medical Center, Houston, Texas. Electronic address:

Background: During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents' career paths, training, and perceptions changed during this period.

Methods: The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors' Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded.

Results: During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p = 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p = 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001).

Conclusions: With the evolution in CTS over the last decade, residents' training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.
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http://dx.doi.org/10.1016/j.athoracsur.2015.04.026DOI Listing
October 2015

Predictors of Career Choice Among Cardiothoracic Surgery Trainees.

Ann Thorac Surg 2015 Nov 7;100(5):1849-54; discussion 1853. Epub 2015 Jul 7.

Memorial Hermann Hospital-Heart and Vascular Institute, University of Texas Medical School at Houston, Houston, Texas. Electronic address:

Background: The impact of factors influencing career choice by cardiothoracic surgery (CTS) trainees remains poorly defined in the modern era. We sought to examine the associations between CTS trainee characteristics and future career aspirations.

Methods: The 2012 Thoracic Surgery In-Training Examination survey results were used to categorize responders according to career interest: congenital, adult cardiac, mixed cardiac/thoracic, and general thoracic surgery. Univariate and multivariable analyses were used to identify and analyze characteristics associated with career interest categories.

Results: With a 100% response rate, 300 responses from trainees in programs accredited by the Accreditation Council for Graduate Medical Education were included in the analysis. Multinomial logistic regression identified three factors associated with career choice in CTS: level of training (p < 0.001), type of training pathway (p < 0.001), and primary motivating factor to pursue CTS (p = 0.002). Trainees interested in general thoracic surgery were more likely to commit to CTS during their senior years of general surgery training and were more likely to enroll in 2-year or 3-year traditional fellowships, whereas individuals pursuing adult or congenital cardiac surgery were more likely to commit earlier during training and were more commonly interested in 6-year integrated or joint training pathways. Moreover, trainees interested in general thoracic surgery were predominantly influenced by early mentorship (p = 0.025 vs adult cardiac), and trainees interested in adult cardiac surgery were more likely to be influenced by types of operations (p = 0.047 vs general thoracic).

Conclusions: Career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. These results demonstrate the importance of maintaining all four currently approved training pathways to retain balance and diversity in future CTS practices.
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http://dx.doi.org/10.1016/j.athoracsur.2015.04.073DOI Listing
November 2015

Resident Perceptions of 2-Year Versus 3-Year Cardiothoracic Training Programs.

Ann Thorac Surg 2015 Jun 8;99(6):2070-5; discussion 2075-6. Epub 2015 Apr 8.

Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York.

Background: Resident perceptions of 2-year (2Y) vs 3-year (3Y) programs have never been characterized. The objective was to use the mandatory Thoracic Surgery Residents Association and Thoracic Surgery Directors Association In-Training Examination survey to compare perceptions of residents graduating from 2Y vs 3Y cardiothoracic programs.

Methods: Each year Accreditation Council for Graduate Medical Education cardiothoracic residents are required to take a 30-question survey designed by the Thoracic Surgery Residents Association and the Thoracic Surgery Directors Association accompanying the In-Training Examination with a 100% response rate. The 2013 and 2014 survey responses of residents graduating from 2Y vs 3Y training programs were compared. The Wilcoxon signed rank test was used to analyze ordinal and interval data.

Results: Graduating residents completed 167 surveys, including 96 from 2Y (56%) and 71 from 3Y (43%) programs. There was no difference in the perception of being prepared for the American Board of Thoracic Surgery examinations or amount of debt between 2Y and 3Y respondents. There was no difference in intended academic vs private practice. Graduating 3Y residents felt more prepared to meet case requirements and better trained, were more likely to pass their written American Board of Thoracic Surgery examinations, and were less likely to pursue additional training beyond their cardiothoracic residency.

Conclusions: There was no difference in field of interest, practice type, and amount of debt between graduating 2Y vs 3Y residents. Respondents from 2Y programs expressed more difficulty in meeting case requirements, whereas residents from 3Y programs felt more prepared for independent practice and had higher American Board of Thoracic Surgery written pass rates.
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http://dx.doi.org/10.1016/j.athoracsur.2015.01.031DOI Listing
June 2015

What a pain!

Authors:
William E Stein

Northwest Dent 2014 Jul-Aug;93(4):12-3

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October 2014

Ethics and old age.

Authors:
William E Stein

Northwest Dent 2014 May-Jun;93(3):8-9

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August 2014

In a perfect world.

Northwest Dent 2014 Mar-Apr;93(2):12-3, 15, 17-8 passim

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June 2014

Wishing for a perfect world.

Authors:
William E Stein

Northwest Dent 2014 Mar-Apr;93(2):11

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June 2014

Training the dragon.

Authors:
William E Stein

Northwest Dent 2014 Jan-Feb;93(1):11

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April 2014

Random thoughts on an autumn evening.

Authors:
William E Stein

Northwest Dent 2013 Nov-Dec;92(6):12-3

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April 2014

We remember Tony.

Authors:
William E Stein

Northwest Dent 2013 Jul-Aug;92(4):11-2

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December 2013

It's fruitcake season.

Authors:
William E Stein

Northwest Dent 2013 May-Jun;92(3):11

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August 2013

How ya doin', sugar?

Authors:
William E Stein

Northwest Dent 2013 Mar-Apr;92(2)

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July 2013

Rambling thoughts on change.

Authors:
William E Stein

Northwest Dent 2013 Jan-Feb;92(1):10-1

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June 2013

Come Friday: thoughts on the ADA annual session.

Authors:
William E Stein

Northwest Dent 2012 Nov-Dec;91(6):11, 36

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February 2013