Gender Is a Spectrum: Evaluating Current and Novel Ways to Inquire About Gender Identity in the Health Care Setting.

PURPOSE: The use of visuals to inquire about gender in the clinical setting has been rare. We developed a survey that included a visual spectrum to assess perceptions about the most and least inclusive ways of inquiring about gender in patients with gender dysphoria. METHODS: The survey included a multiple-choice question (MCQ), free-response question, and a visual spectrum on which respondents were asked to select one box that best depicts their gender. The survey was administered to all patients diagnosed with gender dysphoria at our institution between April and June 2022. RESULTS: A total of 223 of 856 patients responded. Those with more masculine gender identities selected boxes near the visual spectrum corner of "man," whereas responses were more variable for more feminine genders. The free-response question was identified by 59% of respondents as the most inclusive. The MCQ was identified as least inclusive by 70.4%. The visual spectrum was considered the most inclusive method by the majority of patients who self-identified as woman and demiwoman/demifemale. Being asked about pronouns was extremely or very important in the health care setting for 52% of respondents, but 68.6% indicated that they are rarely or sometimes asked about their pronouns in this setting. CONCLUSIONS: The traditional MCQ format for self-identifying gender may be lacking in inclusivity and fails to represent the nuances of gender identity. Free response was considered the most inclusive way to inquire about gender among our respondents. These findings highlight the importance of formatting gender identity questionnaires to foster inclusivity for transgender patients.

Machine learning improves prediction of postoperative outcomes after gastrointestinal surgery: a systematic review and meta-analysis.

BACKGROUND: Machine learning (ML) approaches have become increasingly popular in predicting surgical outcomes. However, it is unknown whether they are superior to traditional statistical methods such as logistic regression (LR). This study aimed to perform a systematic review and meta-analysis to compare the performance of ML vs LR models in predicting postoperative outcomes for patients undergoing gastrointestinal (GI) surgery. METHODS: A systematic search of Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar was performed through December 2022. The primary outcome was the discriminatory performance of ML vs LR models as measured by the area under the receiver operating characteristic curve (AUC). A meta-analysis was then performed using a random effects model. RESULTS: A total of 62 LR models and 143 ML models were included across 38 studies. On average, the best-performing ML models had a significantly higher AUC than the LR models (ΔAUC, 0.07; 95% CI, 0.04-0.09; P < .001). Similarly, on average, the best-performing ML models had a significantly higher logit (AUC) than the LR models (Δlogit [AUC], 0.41; 95% CI, 0.23-0.58; P < .001). Approximately half of studies (44%) were found to have a low risk of bias. Upon a subset analysis of only low-risk studies, the difference in logit (AUC) remained significant (ML vs LR, Δlogit [AUC], 0.40; 95% CI, 0.14-0.66; P = .009). CONCLUSION: We found a significant improvement in discriminatory ability when using ML over LR algorithms in predicting postoperative outcomes for patients undergoing GI surgery. Subsequent efforts should establish standardized protocols for both developing and reporting studies using ML models and explore the practical implementation of these models.

Results of a Pilot Virtual Microsurgery Course for Plastic Surgeons in LMICs.

Background: The Plastic Surgery Foundation's Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program seeks to expand surgical capacity worldwide through mentorship and training for local plastic surgeons. This study aims to define the need for microsurgery training among SHARE global fellows and describe results of a pilot course. Methods: Ten participants of the SHARE Virtual Microsurgical Skills Course were asked to complete an anonymous survey. Pre- and post-course response rates were 100% and 50.0%, respectively. Results: There was a high incidence of microsurgical problems encountered in the clinical setting. Resource availability was varied, with high access to loupes (100%), yet limited access to microsurgery instruments (50%), medications (40%), operating microscope (20%), skilled nursing (0%) and appropriate peri-operative care settings (0%). Participants identified vessel preparation, instrument selection, and suture handling as priority learning objectives for a microsurgery skills course. Post-course satisfaction with learning objectives was high (60% "very good," 40% "excellent"). Participants reported high levels of improvement in suture handling (Likert 4.60±0.55), end-to-end anastomosis (4.40±0.55), instrument selection (4.20±0.45), vessel preparation (4.20±0.45), and economy of motion (4.20±0.45). Conclusions: This study demonstrates a high frequency of reconstructive problems encountered by global fellows yet low access to appropriate resources to perform microsurgical procedures. Initial results from a pilot virtual microsurgery course demonstrate very high satisfaction and high self-rated improvement in key microsurgical skills. The virtual course is an effective and accessible format for training surgeons in basic microsurgery skills and can be augmented by providing longitudinal opportunities for remote feedback.

From a Chicken Model to a Patient: Microsurgical Repair of a Brachial Artery in Mozambique.

In sub-Saharan Africa, options for reconstruction of traumatic injuries are limited due to lack of access to microsurgery-trained surgeons. Recently, the Plastic Surgery Foundation-sponsored Surgeons in Humanitarian Alliance for Reconstruction, Research and Education group hosted a virtual microsurgery skills course for junior plastic surgeons in this region. In this report, we describe a case of complete brachial artery transection requiring microsurgical techniques and use of vein graft for repair at our provincial hospital in Mozambique. By highlighting this case, we aimed to describe a direct clinical application of the Surgeons in Humanitarian Alliance for Reconstruction, Research and Education virtual microsurgery skills course and to demonstrate the profound impact such courses can have on patient outcomes in low-and middle-income countries with limited or no access to microsurgery-trained surgeons. Further, through newly gained familiarity with standard microsurgery instruments used in reconstructive procedures, we were able to improvise and develop modified instruments to overcome lack of resources at our institution.

Impact of ACAPS Coordinated Interview Release Policy: Applicant and Program Attitudes, Adherence, and Interview Trends.

BACKGROUND: The authors studied the impact of a new, coordinated interview release date for integrated plastic surgery residencies. METHODS: A cross-sectional study of all 2020 integrated plastic surgery residencies and applicants was performed. Voluntary, anonymous surveys were administered following implementation of the interview policy. RESULTS: Program response rates were 55.6% for the initial survey and 57.1% for the follow-up survey. Programs released an average of 2.1 (95% CI, 1.8 to 2.4) rounds of interview invitations and invited 39.0 (95% CI, 35.3 to 42.6) applicants to interview. Policy adherence was high (91.1%). Most programs believed the interview policy was an improvement for applicants (46.5% yes; 9.1% no) and programs (41.9% yes; 27.0% no). Median rank of matched candidates was 13, and 55.1% of programs matched candidates within the top quartile of their rank list. The average candidate applied to 72 programs, attended 11 interviews, and ranked 12 programs. Interview distribution was bimodal, with peaks at six and 15 total interview invitations. Applicants within the top fifth, tenth, and fifteenth percentile for total interview invites disproportionately accounted for 15.3%, 26.6%, and 36.5%, respectively, of all invitations received. Survey data suggested applicant satisfaction with travel planning, improved scheduling, and cost savings following implementation of the interview policy. Applicants were somewhat dissatisfied with interview distribution. CONCLUSIONS: A coordinated interview release date is facile to adopt and does not adversely impact program interview trends or match rates. Applicants benefit from improved scheduling, travel planning, and cost savings; however, interview distribution continues to favor top-tier candidates.

Long-Term Treatment Outcomes of Primary Alveolar Bone Grafts for Alveolar Clefts: A Qualitative Systematic Review.

BACKGROUND: Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice. PRIMARY AIM: To provide a qualitative systematic review analysis of long-term outcomes after PABG. MATERIALS AND METHODS: A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings. RESULTS: After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice. CONCLUSION: The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

The Influence of Academic Pedigree on Integrated Plastic Surgery Resident Training Location.

INTRODUCTION: Plastic surgery residencies are among the most competitive programs for graduate medical education. While board scores and research output are well-studied indicators of match success, no studies describe the association between an applicant's medical school ranking and subsequent residency ranking. METHODS: A cross-sectional study of integrated plastic surgery residents for the 2019 to 2020 academic year was performed. Integrated plastic surgery residency programs were ranked according to 2020 Doximity Residency Navigator. AAMC-affiliated allopathic medical schools were ranked according to US News & World Report 2020 Best Medical Schools. Multiple regression analysis was used to determine if academic pedigree predicted placement at highly competitive plastic surgery residency programs. RESULTS: A total of 914 residents across 69 integrated plastic surgery residency programs were included. Ten medical schools accounted for 169 (18.4%) of all trainees. 159 (16.5%) matched at their home program for residency. Medical school ranking and medical school-affiliated integrated plastic surgery program ranking were significant predictors of match success and future residency competitiveness. The presence of an affiliated plastic surgery residency program predicted total number of medical school graduates who matriculated into plastic surgery residency (p < 0.0005). Graduates of top-ranked schools represented a disproportionate number of current plastic surgery residents (Top 10 program: 12.5%, Top 20: 24.1%, Top 40: 40.9%, Top 50: 49.1%). CONCLUSIONS: Both medical school ranking and home plastic surgery program ranking appeared to influence match success and future residency training program competitiveness. This is the first study to demonstrate these associations.

Diversity and Inclusion: A Review of Effective Initiatives in Surgery.

OBJECTIVE: Surgery lacks women and racial minorities that are underrepresented in medicine (UIM). This systematic review evaluates interventions used to promote diversity in surgery. DESIGN: The PubMed (MEDLINE), EMBASE, and Cochrane databases were searched for studies (1) describing interventions for increasing UIM and gender diversity, (2) within surgery, and (3) targeting any learner prior to residency. SETTING: Nine surgical specialties were searched: general, neurosurgery, plastics, orthopedics, otolaryngology, urology, cardiothoracic, vascular, and ophthalmology. RESULTS: Of the 982 studies identified, 16 were included. Awards, clerkships, and workshops were each described by three studies; awards funded research or travel to national meetings, clerkships referred to a third- or fourth-year rotation that provided exposure to surgery, and workshops were hands-on skills sessions for learners. Two studies proposed a holistic review of residency applications, which involves emphasizing an individual's attributes and life experiences rather than strictly academics. Two studies detailed a longitudinal mentoring program comprised of mentorship throughout medical school plus opportunities for research, lectures, and workshops. One study described a combination of interventions and the remaining 2 presented interventions that were characterized as "other." Longitudinal mentoring programs significantly increased the likelihood of women and UIM applying to surgical residency, while holistic review significantly increased the numbers of women and UIM being interviewed and ranked by residency programs. One award increased the number of female residents matriculating into surgical residency. Clerkships significantly increased the number of women applying to surgical residency. The mere mention of diversity initiatives on a program's website was associated with more female surgical residents, but not UIM residents. Workshops led to a higher, but not statistically significant, proportion of women applying to surgery. CONCLUSION: Holistic review and longitudinal mentoring programs are the most effective interventions for increasing UIM and female representation among surgical trainees.

Analysis of Narcotic Use in Isolated Facial Fractures: Potential Targets for a Narcotic Reduction Protocol.

ABSTRACT: Anecdotal evidence suggests that patients with isolated traumatic facial fractures have high narcotic usage, yet there is a lack of literature delineating this relationship. This study aimed to characterize total amount and factors predictive of narcotic usage following isolated traumatic facial fracture. Study participants (n = 35) were predominantly male (91.4%), mean age 40.5, Caucasian (34.3%), suffered some form of assault (62.9%), and remained hospitalized for an average of 3.0 days. Average morphine milligram equivalent (MME) use in the inpatient setting was 967.6 for operative (n = 30) and 37.5 for nonoperative (n = 5) patients. Average total narcotic use across inpatient and outpatient settings was 1256.6 MME for operative and 105 MME for nonoperative patients. Operative intervention predicted a significant difference in total inpatient narcotic usage (P = 0.009). For patients who underwent surgical intervention, significant variations in narcotic usage were found based on mechanism of injury (24-hour postoperative, P = 0.030), but not injury severity or number of procedures. Specifically, individuals suffering highly traumatic fractures (eg, gunshot wound) demonstrated increased total postoperative narcotic usage of 1194.1 MME (P = 0.004). Interestingly, non-narcotic analgesic use including acetaminophen and lidocaine-epinephrine resulted in significantly lower narcotic usage in the postoperative setting. These findings suggest a role for narcotic-reducing enhanced recovery after surgery protocols in the setting of isolated facial trauma.

Can Head Circumference Be Used as a Proxy for Intracranial Volume in Patients With Craniosynostosis?

BACKGROUND: Calculation of intracranial volume from neuroimaging can be complex and time consuming. In the adult population, there is evidence suggesting that owing to its strong correlation, head circumference (HC) may be used as a surrogate for intracranial volume (ICV). We were interested in studying the correlation between HC and ICV in patients with craniosynostosis. METHODS: After institutional review board approval, a retrospective review was performed on patients with craniosynostosis. GE Healthcare AdW 4.3 volume assessment software was used to calculate ICV and HC based on preoperative computed tomographic scans. Pearson correlation was used to estimate correlation coefficients between ICV and HC for this patient population, with 0 to 0.3 considered a weak correlation, 0.4 to 0.6 considered a moderate correlation, 0.7 to 1 considered a strong correlation, and P < 0.05 was considered statistically significant. RESULTS: A total of 196 craniosynostosis patients were included in this study. There were 121 male and 75 female patients. Seventy-nine patients had metopic, 45 had coronal, 64 had sagittal, and 8 had lambdoid synostosis. Mean age was 8.2 months. Mean HC and ICV were 42.9 cm and 829 cm, respectively. Overall, there was a strong correlation between HC and ICV (r = 0.81). Patients were further categorized by craniosynostosis type. Very strong correlation was obtained for patients with coronal (0.89), metopic (0.98), and lambdoid craniosynostosis (0.97). Strong correlation was obtained for patients with sagittal synostosis (0.73). When categorized by sex, a stronger correlation was obtained for female patients (0.84) compared with male patients (0.80). Statistical significance was reached for all reported correlations. CONCLUSION: Our preliminary data suggest that a very strong correlation exists between HC and ICV for male and female patients with all types of craniosynostosis, making HC a useful surrogate for ICV in this patient population.

A Study to Evaluate Change in Ventricular Volume Obtained by Cranial Distraction for Craniosynostosis.

BACKGROUND: The aims of the current analysis were to study the change in ventricular volume (VV) obtained with cranial distraction in patients with craniosynostosis and compare it with the change in total intracranial volume (ICV) and brain volume. METHODS: After institutional review board approval, a retrospective review was performed on patients undergoing cranial distraction over a 5-year period. GE Healthcare AdW 4.3 volume assessment software was utilized to calculate preoperative and postdistraction ICV, VV, and whole-brain volume. Data were also collected on patient demographics, age at the time of distraction, time spent in distraction and consolidation, and length of stay. t Tests were used for comparison. RESULTS: Twenty-three patients met our inclusion criteria. Forty-eight percent of patients (n = 11) had right-sided cranial distraction, 30% (n = 7) had bilateral distraction, and 22% of patients (n = 5) had left-sided distraction. At the preoperative stage, mean head circumference was 42.5 ± 4.7 cm, mean ICV was 810.1 ± 27 cm, mean non-VV (NVV) was 796.2 ± 268 cm, and mean VV was 13.9 ± 9 cm. After a mean of 27.4 mm of distraction, occurring over a mean of 26 days and consolidation period of 149 days, a second computed tomography scan was obtained. Mean postdistraction head circumference was 49.1 ± 3.9 cm, mean ICV was 1074.1 ± 203 cm, mean NVV was 1053.5 ± 197 cm, and VV was 20.6 ± 14 cm. Mean % increase in ICV at this stage was 47.4%; mean % NVV increase was 48.5% as opposed to 60.3% increase in VV. CONCLUSIONS: Cranial distraction is known to effectively increase ICV. Our study suggests that the effect of this volumetric increase is much more pronounced on the VV compared with the brain volume. Further studies are underway to investigate whether this short-term marked increase in VV is sustained over a long-term period.

The Relationship of Cognitive Performance and the Theta-Alpha Power Ratio Is Age-Dependent: An EEG Study of Short Term Memory and Reasoning during Task and Resting-State in Healthy Young and Old Adults.

Objective: The Theta-Alpha ratio (TAR) is known to differ based upon age and cognitive ability, with pathological electroencephalography (EEG) patterns routinely found within neurodegenerative disorders of older adults. We hypothesized that cognitive ability would predict EEG metrics differently within healthy young and old adults, and that healthy old adults not showing age-expected EEG activity may be more likely to demonstrate cognitive deficits relative to old adults showing these expected changes. Methods: In 216 EEG blocks collected in 16 young and 20 old adults during rest (eyes open, eyes closed) and cognitive tasks (short-term memory [STM]; matrix reasoning [RM; Raven's matrices]), models assessed the contributing roles of cognitive ability, age, and task in predicting the TAR. A general linear mixed-effects regression model was used to model this relationship, including interaction effects to test whether increased cognitive ability predicted TAR differently for young and old adults at rest and during cognitive tasks. Results: The relationship between cognitive ability and the TAR across all blocks showed age-dependency, and cognitive performance at the CZ midline location predicted the TAR measure when accounting for the effect of age (p < 0.05, chi-square test of nested models). Age significantly interacted with STM performance in predicting the TAR (p < 0.05); increases in STM were associated with increased TAR in young adults, but not in old adults. RM showed similar interaction effects with aging and TAR (p < 0.10). Conclusion: EEG correlates of cognitive ability are age-dependent. Adults who did not show age-related EEG changes were more likely to exhibit cognitive deficits than those who showed age-related changes. This suggests that healthy aging should produce moderate changes in Alpha and TAR measures, and the absence of such changes signals impaired cognitive functioning.