Sexual Harassment in Surgery-Is Operating Room Culture the Culprit?

BACKGROUND: Sexual harassment is a known problem in surgical training and a focus of growing attention in recent years. However, the environments where sexual harassment in surgical training most commonly takes place are not yet described. METHODS: An anonymous, voluntary, electronic survey was distributed to surgical trainees, and all programs nationally were invited to participate. RESULTS: Sixteen general surgery training programs elected to participate, and the survey achieved a response rate of 30%. 48.9% of respondents reported experiencing sexual harassment. The most common location for harassment was in the operating room (OR) (74% of harassed respondents). The second most common location for harassment was the wards (67.4% of harassed respondents). In the OR, attendings and nurses were the most common harassers. The most common harassment in the OR was being called a sexist slur or intimate nickname. DISCUSSION: Surgical trainees report that the OR was the most common location for trainee harassment. Given that harassment is most commonly perpetrated by both attendings and nurses, harassment in surgical training may not entirely be due to hierarchies but may also be attributed to a flawed and permissive OR culture. Surgical training programs should vigilantly eliminate the circumstances that permit sexual harassment in the OR.

In utero delivery of miRNA induces epigenetic alterations and corrects pulmonary pathology in congenital diaphragmatic hernia.

Structural fetal diseases, such as congenital diaphragmatic hernia (CDH) can be diagnosed prenatally. Neonates with CDH are healthy in utero as gas exchange is managed by the placenta, but impaired lung function results in critical illness from the time a baby takes its first breath. MicroRNA (miR) 200b and its downstream targets in the TGF-ß pathway are critically involved in lung branching morphogenesis. Here, we characterize the expression of miR200b and the TGF-ß pathway at different gestational times using a rat model of CDH. Fetal rats with CDH are deficient in miR200b at gestational day 18. We demonstrate that novel polymeric nanoparticles loaded with miR200b, delivered in utero via vitelline vein injection to fetal rats with CDH results in changes in the TGF-ß pathway as measured by qRT-PCR; these epigenetic changes improve lung size and lung morphology, and lead to favorable pulmonary vascular remodeling on histology. This is the first demonstration of in utero epigenetic therapy to improve lung growth and development in a pre-clinical model. With refinement, this technique could be applied to fetal cases of CDH or other forms of impaired lung development in a minimally invasive fashion.

Surface conjugation of antibodies improves nanoparticle uptake in bronchial epithelial cells.

BACKGROUND: Advances in Molecular Therapy have made gene editing through systemic or topical administration of reagents a feasible strategy to treat genetic diseases in a rational manner. Encapsulation of therapeutic agents in nanoparticles can improve intracellular delivery of therapeutic agents, provided that the nanoparticles are efficiently taken up within the target cells. In prior work we had established proof-of-principle that nanoparticles carrying gene editing reagents can mediate site-specific gene editing in fetal and adult animals in vivo that results in functional disease improvement in rodent models of ß-thalassemia and cystic fibrosis. Modification of the surface of nanoparticles to include targeting molecules (e.g. antibodies) holds the promise of improving cellular uptake and specific cellular binding. METHODS AND FINDINGS: To improve particle uptake for diseases of the airway, like cystic fibrosis, our group tested the impact of nanoparticle surface modification with cell surface marker antibodies on uptake in human bronchial epithelial cells in vitro. Binding kinetics of antibodies (Podoplanin, Muc 1, Surfactant Protein C, and Intracellular Adhesion Molecule-1 (ICAM)) were determined to select appropriate antibodies for cellular targeting. The best target-specific antibody among those screened was ICAM antibody. Surface conjugation of nanoparticles with antibodies against ICAM improved cellular uptake in bronchial epithelial cells up to 24-fold. CONCLUSIONS: This is a first demonstration of improved nanoparticle uptake in epithelial cells using conjugation of target specific antibodies. Improved binding, uptake or specificity of particles delivered systemically or to the luminal surface of the airway would potentially improve efficacy, reduce the necessary dose and thus safety of administered therapeutic agents. Incremental improvement in the efficacy and safety of particle-based therapeutic strategies may allow genetic diseases such as cystic fibrosis to be cured on a fundamental genetic level before birth or shortly after birth.

Engineering alginate microparticles for optimized accumulation in fetal rat myelomeningocele.

INTRODUCTION: Intraamniotic microparticle injection is a novel technique for the treatment of myelomeningocele (MMC) in which microparticles are delivered in-utero in a minimally invasive fashion to bind to and protect the exposed spinal cord. This technique could offer earlier intervention and greater access to prenatal treatment of MMC. Here we demonstrate progress on the engineering of the microparticles to promote binding to the MMC defect. We hypothesized that when the particle's surface charge was decreased and delivery concentration increased, particles would bind to the MMC defect more frequently and more specifically. METHODS: Alginate microparticles underwent surface modification to alter the particle charge. Dye-loaded alginate, alginate- dextran sulfate, and alginate- chitosan were injected on e17 into the amnion of a rat model of MMC and the incidence of successful binding and specificity of particle binding to the MMC defect were calculated. Specificity of binding was described using a defect-to-skin brightness ratio based on specimen imaging. Comparisons were made with chi-square, p< 0.05 marked significance. RESULTS: There was no difference in the incidence of successful binding at e17 with 0.6 mg/fetal kg between the three tested alginate particles. However, alginate- dextran sulfate bound most specifically to the defect (p< 0.05). Alginate-dextran sulfate also demonstrated more frequent binding at higher doses than lower doses (79% at 1.2 mg/kg vs 38% at 0.6 mg/kg and 24% at 0.8 mg/kg, p< 0.01 for both). Specificity was not sacrificed at higher dose injections: defect-to-skin brightness ratio of 5.4 at 1.2 mg/kg vs 1.8 at 0.6 mg/kg (p< 0.05) CONCLUSION: We demonstrate that the intraamniotic injection of alginate-dextran sulfate microparticles at high concentration bind more frequently and more specifically to MMC defects than the previously tested unmodified alginate microparticles.

Diffusion weighted imaging as a biomarker of retinoic acid induced myelomeningocele.

Neural tube defects are a common congenital anomaly involving incomplete closure of the spinal cord. Myelomeningocele (MMC) is a severe form in which there is complete exposure of neural tissue with a lack of skin, soft tissue, or bony covering to protect the spinal cord. The all-trans retinoic acid (ATRA) induced rat model of (MMC) is a reproducible, cost-effective means of studying this disease; however, there are limited modalities to objectively quantify disease severity, or potential benefits from experimental therapies. We sought to determine the feasibility of detecting differences between MMC and wild type (WT) rat fetuses using diffusion magnetic resonance imaging techniques (MRI). Rat dams were gavage-fed ATRA to produce MMC defects in fetuses, which were surgically delivered prior to term. Average diffusion coefficient (ADC) and fractional anisotropy (FA) maps were obtained for each fetus. Brain volumes and two anatomically defined brain length measurements (D1 and D2) were significantly decreased in MMC compared to WT. Mean ADC signal was significantly increased in MMC compared to WT, but no difference was found for FA signal. In summary, ADC and brain measurements were significantly different between WT and MMC rat fetuses. ADC could be a useful complementary imaging biomarker to current histopathologic analysis of MMC models, and potentially expedite therapeutic research for this disease.

Nanoparticles for delivery of agents to fetal lungs.

Fetal treatment of congenital lung disease, such as cystic fibrosis, surfactant protein syndromes, and congenital diaphragmatic hernia, has been made possible by improvements in prenatal diagnostic and interventional technology. Delivery of therapeutic agents to fetal lungs in nanoparticles improves cellular uptake. The efficacy and safety of nanoparticle-based fetal lung therapy depends on targeting of necessary cell populations. This study aimed to determine the relative distribution of nanoparticles of a variety of compositions and sizes in the lungs of fetal mice delivered through intravenous and intra-amniotic routes. Intravenous delivery of particles was more effective than intra-amniotic delivery for epithelial, endothelial and hematopoietic cells in the fetal lung. The most effective targeting of lung tissue was with 250nm Poly-Amine-co-Ester (PACE) particles accumulating in 50% and 44% of epithelial and endothelial cells. This study demonstrated that route of delivery and particle composition impacts relative cellular uptake in fetal lung, which will inform future studies in particle-based fetal therapy.

What's it Worth?: The Costs and Benefits of an Initiative to Decrease Post-Call Fatigued Driving Among Surgery Residents.

BACKGROUND: In 2017 the ACGME enacted new regulations requiring sponsoring institutions to ensure "safe transportation options for residents who may be too fatigued to safely return home." We investigate here the impact of a pilot "Safe Ride" program designed to mitigate the risks of fatigued driving. METHODS: During a 2-month pilot period at a single university-affiliated general surgery residency with four urban clinical sites, all residents (n = 72) were encouraged to hire a rideshare (e.g., Uber, Lyft) to and from 24-h clinical shifts if they felt too fatigued to drive safely. The cost of the rideshare was fully reimbursed to the resident. The impact of this intervention was evaluated using utilization data and a post-intervention resident survey. RESULTS: A total of 16.6% of trainees utilized a rideshare at least one time. Sixty-three post-call rides were taken, predominantly by junior residents (92.4%) and for commutes greater than 15 miles (91%). The cost for the 60-day pilot was $3030. Comparing pre-intervention to post-intervention data, there was a significant improvement in the reported frequency of falling asleep or nearly asleep while driving (P < 0.001). Trainees nearly unanimously (98%) supported efforts to make the program permanent. DISCUSSION: Driving while fatigued is common among surgical residents, with increased risk among junior residents, during longer commutes and following longer shifts. A reimbursed rideshare program effectively targets these risk factors and was associated with a significant decrease in rates of self-reported fatigued driving. Future efforts should focus on strategies to promote use of reimbursed rideshare programs while remaining cost efficient.

Driving Safety Among Surgical Residents in the Era of Duty Hour Restrictions.

OBJECTIVE: Fatigued driving is a known contributor to adverse motor vehicle events (AMVEs), defined as crashes and near misses. Surgical trainees work long and irregular hours; the safety of work-related driving since the introduction of work hour regulations has not yet been studied in this population. We aimed to assess the impact of fatigue on driving safety and explore perceptions of a funded rideshare program. DESIGN: An electronic survey was delivered and inquired in retrospective fashion about fatigue and sleepiness while driving, occurrences of AMVEs, and projected use of a funded rideshare program as a potential solution to unsafe driving. Chi-square testing determined categorical differences between response choices. SETTING: Yale University School of Medicine, Department of Surgery, New Haven, CT-a general surgery program with 4 urban clinical sites positioned along a roughly twenty mile stretch of interstate highway in Southeastern Connecticut. PARTICIPANTS: General Surgery residents at the Yale University School of Medicine. RESULTS: Of 58 respondents (81% response rate), 97% reported that fatigue compromised their safety while driving to or from work. Eighty-three percent reported falling nearly or completely asleep, and 22% reported AMVEs during work-related driving. Junior residents were more likely than Seniors to drive fatigued on a daily-to-weekly basis (69% vs 47%, p = 0.02) and twice as likely to fall asleep on a weekly-to-monthly basis (67% vs 33%, p = 0.02). Despite this, only 7% of residents had ever hired a ride service when fatigued, though 88%, would use a free rideshare service if provided. CONCLUSIONS: Work-related fatigue impairs the driving safety of nearly all residents, contributing to frequent AMVEs. Currently, few residents hire rideshare services. Eliminating the cost barrier by funding a rideshare and encouraging its routine use may protect surgical trainees and other drivers.

Creating an Opioid Recommendation Card for Trainees: Methods, Use, and Impact.

BACKGROUND: In academic hospitals, surgical residents write most of the postoperative prescriptions; yet, few residents are trained on postoperative analgesia. This leads to wide variability in practices and often excess opioid prescribing. We sought to create an opioid guideline pocket card for surgical residents to access when prescribing opioids postoperatively and to evaluate the impact of this initiative. METHODS: A comprehensive literature review was conducted to generate evidence-based procedure-specific opioid recommendations; additional recommendations were formulated via consensus opinion from surgical divisions at an academic institution. A pocket-sized guideline card was developed to include these procedure-specific recommendations as well as opioid guidelines for discharges after inpatient stays, non-opioid analgesic recommendations, access to opioid safety and disposal instructions for patients discharge, an equianalgesic dosing chart, and instructions for naloxone use. The card was distributed to all General Surgery house staff at a university-affiliated hospital in the spring of 2018. Following the distribution, trainees were surveyed on their use of the card. Descriptive statistics were used to analyze the survey. RESULTS: Of 85 trainees, 62 (72.9%) responded to the survey in full; 58% use the card regularly. Of the 27 junior resident respondents, 70.4% use the card at least monthly including 48.1% who use the card daily-to-weekly. Overall, 81.6% of residents changed their opioid-prescribing practices because of this initiative and 89.8% believe the card should continue to be distributed and used. DISCUSSION: An evidence-based guideline card for postoperative analgesia is highly valued and utilized by surgical trainees, especially those most junior in their training.

Application of Advanced Bioinformatics to Understand and Predict Burnout Among Surgical Trainees.

OBJECTIVE: Physician burnout, including surgical trainees, is multidimensional. Input variables used to predict burnout include grit, exhaustion, and financial stress. Each instrument has intrinsic limitations of scope and strength. We hypothesize that bioinformatics methods borrowed from oncogenetics may allow meta-analysis of existing predictive tools to improve identification of subpopulations at highest risk of burnout. DESIGN: A composite survey was created using widely accepted instruments: demographic factors, burnout using the Single-Item Maslach Burnout Inventory Emotional Exhaustion Measure, grit using the Duckworth Grit Scale, occupational fatigue using the Occupational Fatigue Exhaustion/Recovery Scale, financial well-being, perceptions of physician leadership, and attitudes towards robotic surgery. Surveys were analyzed using k-means analysis and supervised/unsupervised clustering. SETTING: Yale General Surgery Residency. PARTICIPANTS: Survey participants consisted of Yale General Surgery residents. Of 70 residents, 53 responded (75.7%). Males comprised 57.1% and each postgraduate year had majority representation, 68.8% to 100%. RESULTS: Unsupervised hierarchical clustering showed heterogeneous resident answer patterns and suggested clusters of responders. To define groups of dissimilar responders, we performed k-means clustering, testing 15 iterations with 50 attempts. The analysis revealed 3 discrete clusters of responders with differential risk for burnout (p = 0.021). The highest risk group demonstrated the lowest grit score, low interest in innovation and leadership, higher financial stress, and concordantly, the highest rates of anxiety, dread, and self-reported burnout. (p = 0.0004; 0.0014; 0.1217; 0.0625; 0.021; 0.0011; 0.0224) CONCLUSIONS: The limited scope of common tools aiming to predict burnout constrains their utility. The machine-learning technique of cluster analysis organizes compound data to describe complex outcomes such as oncologic risks. We apply this analysis technique to create a composite predictor of burnout among surgical residents. Our method determines subgroups of residents sharing unique traits predictive of burnout. Residencies can use this tool to allocate resources to best support resident well-being.

Sexual Harassment in Vascular Surgery Training Programs.

BACKGROUND: Sexual harassment is any unwelcome behavior or obscene remark that affects an individual's work performance or creates an intimidating, hostile, or offensive environment. We sought to examine its presence in vascular surgery training programs, identify factors associated with occurrence, and determine reporting barriers. METHODS: An anonymous survey consisting of questions on frequency of sexual harassment including type/perpetrators/locations; why/how the practice occurs; reporting mechanisms/barriers to reporting; and demographic information was emailed to all vascular surgery trainees in the United States. Descriptive and univariate analysis was performed. RESULTS: Of 498 invitations sent, 133 (27%) completed the survey. Fifty of 133 (38%) thought harassment occurred more commonly in surgical specialties with hierarchy/power dynamics, historical male dominance in field, and ignoring of behavior, being the most common reasons cited that it still occurs. Of 133, 81 (61%) respondents have either experienced (63/133, 47%) or witnessed (18/133, 14%) other trainees being harassed, with calling a sexist slur/intimate nickname being the most common behavior. Those affected were more commonly women (P = 0.0006), with the most common perpetrator being a surgical attending and the most common area of occurrence being the operating room. Reasons for not reporting included believing the behavior was harmless in intent (33/63, 52%) and feeling nothing would come of it if reported (28/63, 44%), but 15/63 (24%) feared repercussions and 15/63 (24%) feeling uncomfortable are identified as a target of sexual harassment. Of 133, 46 respondents were not aware of institutional mechanisms for reporting harassment, with only 70/133 (53%) feeling comfortable reporting to their departmental leadership. CONCLUSIONS: A significant number of vascular surgery trainees have experienced sexual harassment during their training. Over a third of respondents do not know institutional mechanisms for reporting, and almost half do not feel comfortable reporting to departmental leadership. Increasing education on harassment and reporting mechanisms may be necessary in vascular surgery training programs.

Understanding the Barriers to Reporting Sexual Harassment in Surgical Training.

OBJECTIVE: To investigate the occurrence, nature, and reporting of sexual harassment in surgical training and to understand why surgical trainees who experience harassment might not report it. This information will inform ways to overcome barriers to reporting sexual harassment. SUMMARY/ BACKGROUND DATA: Sexual harassment in the workplace is a known phenomenon with reports of high frequency in the medical field. Aspects of surgical training leave trainees especially vulnerable to harassing behavior. The characteristics of sexual harassment and reasons for its underreporting have yet to be studied on the national level in this population. METHODS: An electronic anonymous survey was distributed to general surgery trainees in participating program; all general surgery training programs nationally were invited to participate. RESULTS: Sixteen general surgery training programs participated, yielding 270 completed surveys (response rate of 30%). Overall, 48.9% of all respondents and 70.8% of female respondents experienced at least 1 form of sexual harassment during their training. Of the respondents who experienced sexual harassment, 7.6% reported the incident. The most common cited reasons for nonreporting were believing that the action was harmless (62.1%) and believing reporting would be a waste of time (47.7%). CONCLUSION: Sexual harassment occurs in surgical training and is rarely reported. Many residents who are harassed question if the behavior they experienced was harassment or feel that reporting would be ineffectual-leading to frequent nonreporting. Surgical training programs should provide all-level education on sexual harassment and delineate the best mechanism for resident reporting of sexual harassment.

An Evidence-Based Guideline Supporting Restricted Opioid Prescription after Pediatric Appendectomy.

BACKGROUND/PURPOSE: Surgeon overprescription of opioids is a modifiable contributor to the opioid epidemic. No clear guidelines exist for prescribing opioids to younger patients after surgery. We sought to determine postoperative opioid needs in pediatric/young adult patients after laparoscopic appendectomy. METHODS: Patients 5-20 years old who underwent laparoscopic appendectomy were included for study. All consented patients underwent chart review and were additionally called for an attempted interview. Caregivers were queried on analgesic use and adequacy of pain relief. The main outcome measures were: quantity of opioid used, desire for an opioid, presence of pain ≥4/10, and need for follow-up/call owing to pain. All opioids were converted into morphine milligram equivalents (MME). RESULTS: Seventy-three patients qualified for the study, 49 of whom completed a postoperative telephone interview. Of the interviewees, 83% did not use or desire an opioid and reported pain <4/10 after discharge. Five patients used an opioid upon discharge, and the average MME consumed was 23 (equivalent to 3 pills of 5 mg oxycodone). No zero-opioid patients had unanticipated follow-up for pain concerns. CONCLUSIONS: After hospital discharge following laparoscopic appendectomy, most patients have adequate analgesia without opioids. Opioid prescriptions should be offered sparingly and for no more than 25 MME. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Prognosis study.

Pancreatic Intraductal Papillary Mucinous Neoplasm With Elevated Pre-Operative Cystic Carcinoembryonic Antigen Level: A Histopathologic Correlation.

BACKGROUND: To study the relationship between carcinoembryonic antigen (CEA) level, intraductal papillary mucinous neoplasm (IPMN) subtype, and the presence of invasive carcinoma. METHODS: Cystic CEA level and the following pathologic variables: subtypes of IPMN, size of cystic lesion, presence of dysplasia or carcinoma, and main or branch duct involvement from 45 IPMN cases were analyzed. RESULTS: There was a significant correlation between pre-operative cystic fluid CEA level and the intensity of luminal CEA staining. However, there was no correlation between CEA level and cystic mucinous secretions or mucinous epithelial cytoplasm CEA staining, mucin glycoprotein expression, size of lesion, grade of dysplasia or presence of invasive carcinoma. CEA level was neither sensitive nor specific for the presence of invasive carcinoma. CONCLUSIONS: Cystic CEA level may not be a reliable determinant of the presence or absence of invasive carcinoma in IPMNs, and its use to assess risk of malignancy may be limited.

No refills: The durable impact of a multifaceted effort by surgical trainees to minimize the prescription of postoperative opioids.

BACKGROUND: Surgeons have the opportunity to help offset the opioid epidemic by leading with practice changes. We sought to decrease the amount of opioid prescribed postoperatively through a multifaceted program. METHODS: A multipronged program was introduced in our hospital system, which included resident education on prescribing for postoperative analgesia, a change in the default number of opioid pills in an electronic medication order entry system, and the distribution of a guideline card of recommended postoperative opioid prescription amounts. The amount of opioid prescribed postoperatively between January 2016 and August 2018 was collected for the 10 most common short-stay (<48 hours) general surgery procedures. The 6 months prior to any intervention (pre-intervention) was compared to the last 6 months of data collection (post-intervention). RESULTS: In the study, 14,007 operations were captured, including 2,530 pre-intervention and 2,715 post-intervention. The average amount of postoperative opioid prescribed in the pre-intervention period was 207.1 morphine milligram equivalents; post-interventions, the average amount declined to 104.6 morphine milligram equivalents (P < .01). The opioid refill rate remained the same (3.3% pre-intervention vs 3.1% post-intervention, P = .76). CONCLUSION: A comprehensive program to eliminate the over-prescription of opioids decreased the amount of opioid prescribed by half, without a concurrent increase in opioid refills, demonstrating that simple measures can be used to deliver sustained and reproducible improvements in offering source control in the opioid epidemic.

Delay in operation for Hirschsprung Disease is associated with decreased length of stay: a 5-Year NSQIP-Peds analysis.

OBJECTIVE: The optimal timing of a pull-through procedure for Hirschsprung Disease is unknown. We, therefore, compared outcomes of pull-throughs performed in the first 30 days of age to 31-120 days. STUDY DESIGN: Retrospective review of 282 patients in the NSQIP-Peds database from 2012-2016 of infants ≤120-days old and >36-weeks gestational age with Hirschsprung Disease who underwent primary pull-through. Primary outcome was postoperative and total length of stay (LOS). Operative morbidity and readmissions were also compared. RESULTS: Postoperative LOS in <31-day group was 8.3 days (SD- 8.3) vs. 4.3 days (SD- 5.5) in 31-120-day group (p < 0.001). This finding was maintained on multivariate linear regression. Complication and readmission rates did not differ between groups (readmission: 15.6 vs 13% p = 0.51; complication: 5.5 vs 10% p = 0.16). CONCLUSION: For appropriately selected patients with Hirschsprung Disease, delaying pull-through until the second month of life is associated with lower total and postoperative stays without increased readmissions or complications.

Role of Adjuvant Multimodality Therapy After Curative-Intent Resection of Ampullary Carcinoma.

Importance: Ampullary adenocarcinoma is a rare malignant neoplasm that arises within the duodenal ampullary complex. The role of adjuvant therapy (AT) in the treatment of ampullary adenocarcinoma has not been clearly defined. Objective: To determine if long-term survival after curative-intent resection of ampullary adenocarcinoma may be improved by selection of patients for AT directed by histologic subtype. Design, Setting, and Participants: This multinational, retrospective cohort study was conducted at 12 institutions from April 1, 2000, to July 31, 2017, among 357 patients with resected, nonmetastatic ampullary adenocarcinoma receiving surgery alone or AT. Cox proportional hazards regression was used to identify covariates associated with overall survival. The surgery alone and AT cohorts were matched 1:1 by propensity scores based on the likelihood of receiving AT or by survival hazard from Cox modeling. Overall survival was compared with Kaplan-Meier estimates. Exposures: Adjuvant chemotherapy (fluorouracil- or gemcitabine-based) with or without radiotherapy. Main Outcomes and Measures: Overall survival. Results: A total of 357 patients (156 women and 201 men; median age, 65.8 years [interquartile range, 58-74 years]) underwent curative-intent resection of ampullary adenocarcinoma. Patients with intestinal subtype had a longer median overall survival compared with those with pancreatobiliary subtype (77 vs 54 months; P = .05). Histologic subtype was not associated with AT administration (intestinal, 52.9% [101 of 191]; and pancreatobiliary, 59.5% [78 of 131]; P = .24). Patients with pancreatobiliary histologic subtype most commonly received gemcitabine-based regimens (71.0% [22 of 31]) or combinations of gemcitabine and fluorouracil (12.9% [4 of 31]), whereas treatment of those with intestinal histologic subtype was more varied (fluorouracil, 50.0% [17 of 34]; gemcitabine, 44.1% [15 of 34]; P = .01). In the propensity score-matched cohort, AT was not associated with a survival benefit for either histologic subtype (intestinal: hazard ratio, 1.21; 95% CI, 0.67-2.16; P = .53; pancreatobiliary: hazard ratio, 1.35; 95% CI, 0.66-2.76; P = .41). Conclusions and Relevance: Adjuvant therapy was more frequently used in patients with poor prognostic factors but was not associated with demonstrable improvements in survival, regardless of tumor histologic subtype. The value of a multimodality regimen remains poorly defined.

Opioid Prescribing Habits of General Versus Pediatric Surgeons After Uncomplicated Laparoscopic Appendectomy.

BACKGROUND: Adolescents who use prescription opioids have an increased risk for future drug abuse and overdose, making them a high-risk population. Appendectomy is one of the most common surgical procedures in this age group, often requires opioid analgesia, and is performed by both pediatric and general surgeons. Prescription patterns comparing these two provider groups have not yet been evaluated; we hypothesize that general surgery providers prescribe more opioids for adolescent and young adult patients than do pediatric surgery providers. METHODS: A retrospective chart review was conducted across a single health system consisting of four hospitals. All uncomplicated laparoscopic appendectomies performed between January 1, 2016 and August 14, 2017 on patients aged 7-20 were included for analysis. Any case coded for multiple procedures, identified as converted to open, or had a length of stay >48 h were excluded. The primary outcome measure was amount of opioid prescribed postoperatively. To standardize different formulations and types of analgesia prescribed, prescriptions were converted into oral morphine equivalents (OMEs). For reference, one 5 mg pill of oxycodone equals 7.5 OME. Linear regression was performed controlling for patient weight, gender, race, insurance status, provider type (pediatric versus general surgery), and provider level (resident, advanced practice provider, and attending). RESULTS: A total of 336 pediatric laparoscopic appendectomies were analyzed, 148 by general surgeons and 188 by pediatric surgeons. Pediatric surgeons prescribed less opioid than general surgeons overall (59 OME versus 90 OME, P < 0.0001). For patients aged <13 y, there was no significant difference between pediatric (26 OME) and general (37 OME, P = 0.8921) surgeons. However, for the age group 13-20 y, pediatric surgeons prescribed 25% less opioid than general surgeons (90 OME versus 112.5 OME, P < 0.0001). Regression analysis demonstrated that being cared for by a general surgery service (+24.1 OME [95% confidence interval 9.8-38.3]) was associated with high prescribing, whereas having Medicaid was associated with lower prescription amounts (-16.4 OME [95% confidence interval -32.5 to -0.3]). CONCLUSIONS: After an uncomplicated laparoscopic appendectomy, general surgeons prescribe significantly more opioid to adolescent patients than do pediatric surgeons, even when controlling for age and weight. One substantial and modifiable contributor of the opioid epidemic is the amount of opioid prescribed. The variability of prescribing habits to adolescents and young adults demonstrates a clear need for increased education and guidelines on this topic, especially for surgeons who do not frequently treat the younger and more vulnerable population.

The impact of a curriculum on postoperative opioid prescribing for novice surgical trainees.

BACKGROUND: Surgical residents are frequently responsible for prescribing postoperative analgesia, yet the vast majority are never formally educated on the subject. METHODS: A resident-led educational presentation on postoperative analgesia prescribing was provided to incoming surgical interns at a tertiary academic center. Pre- and post-surveys assessed comfort in prescribing postoperative analgesia. Following the educational intervention, opioid prescriptions during the interns' first two months were compared to that of the prior year's interns. RESULTS: Education was provided to 31 interns. Prior to the session, few interns felt comfortable prescribing opioids (20%) or non-opioid analgesia (32%). After the session, 96% felt more comfortable prescribing opioids and 91% more comfortable prescribing multi-modal analgesia. Interns who received education prescribed an average of 127.8 Morphine Milligram Equivalents (MME) per prescription, compared to 208.5 MME by the prior year's interns (p < 0.01). CONCLUSION: Education on postoperative analgesia targeting interns can be effective in preparing trainees in effective and judicious analgesic prescribing.