Neighborhood-level Disparities in Achievement of Social Continence Among School-aged Children With Anorectal Malformations: A Single-center Retrospective Study.

BACKGROUND: Fecal incontinence is a common problem for children with repaired anorectal malformations (ARM) and has significant implications for initiating school. While sex, anatomy, and medical comorbidities are known to influence continence outcomes, the impact of socioeconomic factors and neighborhood-level disadvantage are less well understood. METHODS: We performed a single-center retrospective review of all school-aged (5-18 years) children with ARM at a longitudinal pediatric surgery clinic. Demographic, clinical, and socioeconomic variables were abstracted via chart review and geocoding was performed to obtain Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) scores. Statistical analyses assessed for associations between the primary outcome of social continence (defined as no diaper usage and infrequent fecal accidents at age 5) and these variables. RESULTS: 72 patients were included; of these, 45.8% were socially continent. On bivariate analysis, social continence was significantly associated with state ADI score as well as the SVI Housing characteristics score. These associations remained significant when adjusting for sex and medical comorbidities in separate multiple logistic regression models. CONCLUSION: The relative disadvantage of the neighborhood in which a child with ARM lives may play a role in their ability to achieve continence by school age. Efforts are warranted to identify and develop targeted interventions to for this pediatric population. LEVEL OF EVIDENCE: IV.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons.

Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons. Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender. Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience. Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons. Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals. Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Artificial intelligence based real-time video ergonomic assessment and training improves resident ergonomics.

BACKGROUND: Surgery demands long hours and intense exertion raising ergonomic concerns. We piloted a sensorless artificial intelligence (AI)-assisted ergonomics analysis app to determine its feasibility for use with residents. METHODS: Surgery residents performed simulated laparoscopic tasks before and after a review of the SCORE ergonomics curriculum while filmed with a sensorless app from Kinetica Labs that calculates joint angles as a metric of ergonomics. A survey was completed before the session and a focus group was conducted after. RESULTS: Thirteen surgical residents participated in the study. The brief intervention took little time and residents improved their ergonomic scores in neck and right shoulder angles. Residents expressed increased awareness of ergonomics based on the session content and AI information. All trainees desired more training in ergonomics. CONCLUSIONS: Ergonomic assessment AI software can provide immediate feedback to surgical trainees to improve ergonomics. Additional studies using sensorless AI technology are needed.

Cost-effectiveness of Staple Line Reinforcement in Laparoscopic Sleeve Gastrectomy.

OBJECTIVE: To perform a cost-effectiveness analysis of staple-line reinforcement in laparoscopic sleeve gastrectomy. SUMMARY OF BACKGROUND DATA: Exponential increases in surgical costs have underscored the critical need for evidence-based methods to determine the relative value of surgical devices. One such device is staple-line reinforcement, thought to decrease bleeding rates in laparoscopic sleeve gastrectomy. METHODS: Two intervention arms were modeled, staple-line reinforcement and standard nonreinforced stapling. Bleed and leak rates and 30-day treatment costs were obtained from national and state registries. Quality-adjusted life-year (QALY) values were drawn from previous literature. Device prices were drawn from institutional data. A final incremental cost-effectiveness ratio was calculated, and one-way and probabilistic sensitivity analyses were performed. RESULTS: A total of 346,530 patient records from 2012 to 2018 were included. Complication rates for the reinforced and standard cohorts were 0.05% for major bleed in both cohorts ( P = 0.8841); 0.45% compared with 0.59% for minor bleed ( P < 0.0001); and 0.24% compared with 0.26% for leak ( P = 0.4812). Median cost for a major bleed was $5552 ($3287, $16,817) and $2406 ($1861, $3484) for a minor bleed. Median leak cost was $9897 ($4589, $21,619) and median cost for patients who did not experience a bleed, leak, or other serious complication was $1908 ($1712, $2739). Mean incremental cost of reinforced stapling compared with standard was $819.60/surgery. Net QALY gain with reinforced stapling compared with standard was 0.00002. The resultant incremental cost-effectiveness ratio was $40,553,000/QALY. One-way and probabilistic sensitivity analyses failed to produce a value below $150,000/QALY. CONCLUSIONS: Compared with standard stapling, reinforced stapling reduces minor postoperative bleeding but not major bleeding or leaks and is not cost-effective if routinely used in laparoscopic sleeve gastrectomy.

Pragmatic Mentoring Strategies for the Busy Surgeon Scientist.

OBJECTIVE: The value of research mentorship in academic medicine is well-recognized, yet there is little practical advice for how to develop and sustain effective mentoring partnerships. Gaining research skill and mentorship is particularly critical to success in academic surgery, yet surgeon scientists are challenged in their mentorship efforts by time constraints and lack of education on how to mentor. To address this gap, this study explored the strategies that award-winning faculty mentors utilize in collaborating with their medical student mentees in research. DESIGN, SETTING, AND PARTICIPANTS: For this qualitative study, the authors invited physician recipients of an institution-wide mentorship award to participate in individual, semi-structured interviews during July and August 2018. Following interview transcription, the authors independently coded the text and collaboratively identified common mentoring strategies and practices via a process of thematic analysis. RESULTS: Nine physician mentors, representing a mix of genders, medical specialties and types of research (basic science, clinical, translational, and health services), participated in interviews. The authors identified 12 strategies and practices from the interview transcripts that fell into 5 categories: Initiating the partnership; Determining the research focus; Providing project oversight; Developing mentee research competence; and Supporting mentee self-efficacy. CONCLUSION: Award-winning mentors employ a number of shared strategies when mentoring medical trainees in research. These strategies can serve as a guide for academic surgeons who wish to improve their research mentoring skills.

Graft Survival and Segment Discards Among Split-Liver and Reduced-Size Transplantations in the United States From 2008 to 2018.

Split-liver transplantation has allocation advantages over reduced-size transplantation because of its ability to benefit 2 recipients. However, prioritization of split-liver transplantation relies on the following 3 major assumptions that have never been tested in the United States: similar long-term transplant recipient outcomes, lower incidence of segment discard among split-liver procurements, and discard of segments among reduced-size procurements that would be otherwise "transplantable." We used United Network for Organ Sharing Standard Transplant Analysis and Research data to identify all split-liver (n = 1831) and reduced-size (n = 578) transplantation episodes in the United States between 2008 and 2018. Multivariable Cox proportional hazards modeling was used to compare 7-year all-cause graft loss between cohorts. Secondary analyses included etiology of 30-day all-cause graft loss events as well as the incidence and anatomy of discarded segments. We found no difference in 7-year all-cause graft loss (adjusted hazard ratio [aHR], 1.1; 95% confidence interval [CI], 0.8-1.5) or 30-day all-cause graft loss (aHR, 1.1; 95% CI, 0.7-1.8) between split-liver and reduced-size cohorts. Vascular thrombosis was the most common etiology of 30-day all-cause graft loss for both cohorts (56.4% versus 61.8% of 30-day graft losses; P = 0.85). Finally, reduced-size transplantation was associated with a significantly higher incidence of segment discard (50.0% versus 8.7%) that were overwhelmingly right-sided liver segments (93.6% versus 30.3%). Our results support the prioritization of split-liver over reduced-size transplantation whenever technically feasible.

Fostering Passion and Skills in Surgical Research Across the Medical Education Continuum: The Transplant Research, Education, and Engagement Group.

OBJECTIVE: We describe a multilevel, collaborative research group for trainees and faculty engaging in transplant surgery research within one institution. DESIGN: Transplant Research, Education, and Engagement (TREE) was designed to develop trainees' research skills and foster enthusiasm in transplant surgery along the educational continuum. Our research model intentionally empowers junior researchers, including undergraduates and medical students, to assume active roles on a range of research projects and contribute new ideas within a welcoming research and learning environment. SETTING: Section of Transplant Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan. PARTICIPANTS: Undergraduate premedical students, first through fourth year medical students, general surgery residents, transplant surgery fellows, and transplant surgery faculty. RESULTS: TREE was founded in September 2019 and has grown to include over 30 active members who meet weekly and collaborate virtually on a range of research projects, many of which are led by students. Trainees can assume both mentee and mentor roles and build their research, presentation and writing skills while collaborating academically. CONCLUSIONS: Our model has increased trainees' engagement in transplant research projects and fosters early enthusiasm for the field. This model can be feasibly replicated at other institutions and within other subspecialties.

Introduction to the Best-Case/Worst-Case Framework Within Transplantation Surgery to Improve Decision-Making for Increased Risk Donor Organ Offers.

Public Health Service increased risk donor kidneys are discarded 50% more often than nonincreased risk donor kidneys despite equivalent patient and graft survival outcomes. Patient and provider biases as well as challenges in risk interpretation contribute to the underuse of increased risk donor organs. As the ultimate decision to accept or reject an increased risk donor organ results from the patient-provider conversation, there is an opportunity to improve this dialogue. This report introduces the best-case/worst-case communication guide for structuring high-stake conversations on increased risk kidney offers between transplant providers and their patients. Through best case/worst case, providers focus on eliciting patient values and long-term goals. The patient's unique context can then inform an individualized discussion of "best," "worst," and "most likely" outcomes and support the provider's ultimate recommendation. Transplant providers are encouraged to adopt this communication strategy to enhance shared decision-making and improve patient outcomes.

Knowing Your Team: Rapid Assessment of Residents and Fellows for Effective Horizontal Care Delivery in Emergency Events.

BACKGROUND: Horizontal care, in which clinicians assume roles outside of their usual responsibilities, is an important health care systems response to emergency situations. Allocating residents and fellows into skill-concordant clinical roles, however, is challenging. The most efficient method to accomplish graduate medical education (GME) assessment and deployment for horizontal care is not known. OBJECTIVE: We designed a categorization schema that can efficiently facilitate clinical and educational horizontal care delivery for trainees within a given institution. METHODS: In September 2019, as part of a general emergency response preparation, a 4-tiered system of trainee categorization was developed at one academic medical center. All residents and fellows were mapped to this system. This single institution model was disseminated to other institutions in 2020 as the COVID-19 pandemic began to affect hospitals nationally. In March 2020, a multi-institution collaborative launched the Trainee Pandemic Role Allocation Tool (TPRAT), which allows institutions to map institutional programs to COVID-19 roles within minutes. This was disseminated to other GME programs for use and refinement. RESULTS: The emergency response preparation plan was disseminated and selectively implemented with a positive response from the emergency preparedness team, program directors, and trainees. The TPRAT website was visited more than 100 times in the 2 weeks after its launch. Institutions suggested rapid refinements via webinars and e-mails, and we developed an online user's manual. CONCLUSIONS: This tool to assess and deploy trainees horizontally during emergency situations appears feasible and scalable to other GME institutions.

Going the distance for procurement of donation after circulatory death livers for transplantation-Does reimbursement reflect reality?

Donation after circulatory death (DCD) liver transplantation (LT) has increased slowly over the past decade. Given that transplant surgeons generally determine liver offer acceptance, understanding surgeon incentives and disincentives is paramount. The purpose of this study was to assess aggregate travel distance per successful DCD versus deceased after brain death (DBD) liver procurement as a surrogate for surgeon time expenditure and opportunity cost. All consecutive liver offers made to Michigan Medicine from 2006 to 2017 were analyzed. Primary outcome was the summative travel distance (spent on all attempted procurements) per successful liver procurement that resulted in LT. Donation after circulatory death liver offer acceptance was lower than DBD liver offers, as was proportion of successful procurements among accepted offers. Overall, 10 275 miles were travelled for accepted DCD liver offers, resulting in 23 successful procurements (mean 447 miles per successful DCD liver procurement). For accepted DBD liver offers, 197 299 miles were travelled, resulting in 863 successful procurements (mean 229 miles per successful DBD liver procurement). On average, each successful DCD liver procurement required 218 more miles of travel than each successful DBD liver procurement. Current reimbursement policies poorly reflect increased surgeon travel (and time) expenditures between DCD and DBD liver offers.

Competency Committees in Undergraduate Medical Education: Approaching Tensions Using a Polarity Management Framework.

Implementing competency-based medical education in undergraduate medical education (UME) poses similar and unique challenges to doing so in graduate medical education (GME). To ensure that all medical students achieve competency, educators must make certain that the structures and processes to assess that competency are systematic and rigorous. In GME, one such key structure is the clinical competency committee. In this Perspective, the authors describe the University of Michigan Medical School's (UMMS's) experience with the development of a UME competency committee, based on the clinical competency committee model from GME, and the first year of implementation of that committee for a single cohort of matriculating medical students in 2016-2017.The UMMS competency committee encountered a number of inter dependent but opposing tensions that did not have a correct solution; they were "both/and" problems to be managed rather than "either/or" decisions to be made. These tensions included determining the approach of the committee (problem identification versus developmental); committee membership (curricular experts versus broad-based membership); student cohort makeup (phase-based versus longitudinal); data analyzed (limited assessments versus programmatic assessment); and judgments made (grading versus developmental competency assessment).The authors applied the Polarity Management framework to navigate these tensions, leveraging the strengths of each while minimizing the weaknesses. They describe this framework as a strategy for others to use to develop locally relevant and feasible approaches to competency assessment in UME.

Characterizing Pediatric Tuberculosis with and without Human Immunodeficiency Virus Coinfection in Harare, Zimbabwe.

Pediatric tuberculosis (TB) represents a major barrier to reducing global TB mortality, especially in countries confronting dual TB and human immunodeficiency virus (HIV) epidemics. Our study aimed to characterize pediatric TB epidemiology in the high-burden setting of Harare, Zimbabwe, both to fill the current knowledge gap around the epidemiology of pediatric TB and to indicate areas for future research and interventions. We analyzed de-identified data of 1,051 pediatric TB cases (0-14 years) found among a total of 11,607 TB cases reported in Harare, Zimbabwe, during 2011-2012. We performed Pearson's χ2 test and multivariate logistic regression analysis to characterize pediatric TB and to assess predictors of HIV coinfection. Pediatric TB cases accounted for 9.1% of all TB cases reported during 2011-2012. Approximately 50% of pediatric TB cases were children younger than 5 years. Almost 60% of the under-5 age group were male, whereas almost 60% of the 10-14 age group were female. The overall HIV coinfection rate was 58.3%. Odds for HIV coinfection was higher for the 5-9 age group (adjusted odds ratio [AOR]: 2.77, 95% confidence interval [CI]: 1.97-3.94), the 10-14 group (AOR: 3.57, 95% CI: 2.52-5.11), retreatment cases (AOR: 6.17, 95% CI: 2.13, 26.16), and pulmonary TB cases (AOR: 2.39, 95% CI: 1.52, 3.75). In conclusion, our study generated evidence that pediatric TB, compounded by HIV coinfection, significantly impacts children in high-burden settings. The findings of our study indicate a critical need for targeted interventions.

Human cord blood-derived unrestricted somatic stem cells promote wound healing and have therapeutic potential for patients with recessive dystrophic epidermolysis bullosa.

Human umbilical cord blood (CB)-derived unrestricted somatic stem cells (USSCs) have previously been demonstrated to have a broad differentiation potential and regenerative beneficial effects when administered in animal models of multiple degenerative diseases. Here we demonstrated that USSCs could be induced to express genes that hallmark keratinocyte differentiation. We also demonstrated that USSCs express type VII collagen (C7), a protein that is absent or defective in patients with an inherited skin disease, recessive dystrophic epidermolysis bullosa (RDEB). In mice with full-thickness excisional wounds, a single intradermal injection of USSCs at a 1-cm distance to the wound edge resulted in significantly accelerated wound healing. USSC-treated wounds displayed a higher density of CD31(+) cells, and the wounds healed with a significant increase in skin appendages. These beneficial effects were demonstrated without apparent differentiation of the injected USSCs into keratinocytes or endothelial cells. In vivo bioluminescent imaging (BLI) revealed specific migration of USSCs modified with a luciferase reporter gene, from a distant intradermal injection site to the wound, as well as following systemic injection of USSCs. These data suggest that CB-derived USSCs could significantly contribute to wound repair and be potentially used in cell therapy for patients with RDEB.