Masculinizing chest surgery for gender affirmation: A retrospective study of outcomes and patient reported satisfaction.

BACKGROUND: Masculinizing chest surgery is the most common gender-affirming surgery. The objective of our study is to report the surgical and patient reported outcomes of surgery performed by a breast surgery practice. METHODS: Between June 1, 2017 and December 31, 2019, eighty-one patients underwent surgery at a university-affiliated hospital. This study included a retrospective chart review and an anonymous survey. RESULTS: Seventy-five (93%) patients underwent double incision technique. Complications occurred in 25% of patients and two patients required reoperation within 30 days of surgery. The anonymous survey response rate was 47% (34/72). Patients were asked to rate their satisfaction with the cosmetic appearance and the median score was 90. Quality of life and mental health improvement was reported by most patients. Median follow up was 9 months. CONCLUSIONS: Masculinizing chest surgery performed by surgeons trained in breast surgery had a low rate of surgical complications and positive patient reported outcomes.

Hotter Than It Looks: A Retrospective Review of Patients With Cholecystitis and With Negative Imaging.

INTRODUCTION: Ultrasound is the gold standard for workup of cholecystitis in the emergency department, and findings heavily influence clinical decision-making. Patients with negative imaging for acute cholecystitis may be inappropriately sent home. The purpose of our study was to review the pathology and outcomes of patients presenting with biliary pain and negative ultrasound findings of acute cholecystitis. MATERIALS AND METHODS: Emergency department patients who underwent laparoscopic cholecystectomy between January 2015 and February 2019 were reviewed retrospectively. Only patients with negative or equivocal imaging were included. The primary outcome was the incidence of cholecystitis on final pathology. RESULTS: Two hundred fifty-seven patients underwent laparoscopic cholecystectomy. Pathology demonstrated cholecystitis in 84% of patients. Only 15% of patients had cholelithiasis without cholecystitis on pathology. The incidence of cholecystitis was similar in negative and equivocal imaging groups (84% versus 83%; P = 0.960). The median time from admission to the operating room was 12.1 h (interquartile range 7.1-18.3 h), and hospital length of stay was 1.2 d (interquartile range 0.8-1.7 d). CONCLUSIONS: This study found that patients with negative or equivocal imaging had cholecystitis on pathology. On review of patient outcomes, those patients who underwent surgical intervention had a low rate of complications and short hospital stay.

Tumor and serum levels of per- and polyfluoroalkyl (PFAS) in hepatobiliary and gastrointestinal malignancy.

BACKGROUND: There has been significant controversy over the carcinogenic potential of per- and polyfluoroalkyl substances (PFAS). STUDY DESIGN: A total of 37 serum and tumor samples from patients with hepatobiliary and gastrointestinal malignancy were tested for 24 analytes of PFAS. RESULTS: At least one PFAS analyte was found in 97% (36/37) of the serum samples and 41% (15/37) of the tumor samples. The serum Perfluorooctanesulfonic acid (PFOS) levels were significantly higher than the national levels (6.77 ng/mL vs. 5.20 ng/mL; p = 0.038). Patients with PFOS in tumor samples had significantly higher levels in serum when compared to tumor samples without PFOS (9.4 ng/mL vs 5.5 ng/mL; p = 0.015). CONCLUSIONS: Patients were found to have significantly higher levels of PFOS when compared to the reported national levels. Additionally, the patients with higher serum levels of PFOS also had tumor positive samples.

Transgender Surgery: Perspectives Across Levels of Training in Medical and Surgical Specialties.

Purpose: Approximately 1.4 million adults identify as transgender in the United States. Transgender patients face societal, legal, and medical discrimination that can lead to health disparities. The objective of this study was to evaluate knowledge and perceptions of transgender health care across various levels of medical training and specialties. Methods: Between April 1, 2019 and May 1, 2019, an anonymous survey was distributed to residents and attendings, in both medical and surgical specialties, at a university-affiliated hospital. Participants were recruited into the study with survey distribution by email to residency program directors, residents, and residency-affiliated attendings. Results: There was a response rate of 29.5% (118/400). Across all respondents, 34.7%, 31.4%, and 39% knew where to refer transgender patients for hormone replacement, psychotherapy, or surgery, respectively. Only 37.9% of residents and 46.2% of attendings reported that they were confident of providing care for a transgender patient (p=0.130). In addition, less than one-third of surgical respondents reported sufficient knowledge to describe transgender surgery. The most common reasons affecting comfort level when caring for transgender patients were lack of exposure (53.4%) and lack of formal education (47.6%), with other reasons being personal, moral, and religious reasons (11%, 8.5%, and 6.8%, respectively). Conclusion: Despite literature demonstrating the effectiveness of formal didactics and education in transgender health, there remain disparities in the knowledge and comfort of residents and attendings across all specialties. To deliver competent health care to transgender patients, efforts must focus on improving the availability of system-wide resources and educational opportunities for all specialties.

Rib Fracture Mortality: Are There Clues in the Core?

BACKGROUND: Sarcopenia is associated with increased morbidity and mortality in the trauma patient. The primary objective of this study was to determine the relationship of psoas cross sectional area with hospital mortality in patients with rib fractures over the age of 55 years. MATERIALS AND METHODS: We retrospectively reviewed 1223 patients presenting to a Level 1 Trauma Center between 1/1/2002 and 1/31/2019. Psoas cross sectional area was measured using a polygonal tracing tool. Patients were stratified into four quartiles based on sex-specific values. RESULTS: There was increased in-hospital mortality for patients with a lower psoas cross sectional area (10 %, 8%, 6%, and 4%, Q1-Q4 respectively; P=0.021). The logistic regression model determined for every increase in psoas cross sectional area by 1 cm2 the odds of in-hospital mortality decreased by 4%. CONCLUSIONS: In-hospital mortality is multifactorial; however, psoas cross sectional area may provide a clue in predicting adverse outcomes after traumatic rib fractures.

A Prospective Observational Study Comparing Effects of Call Schedules on Surgical Resident Sleep and Physical Activity Using the Fitbit.

BACKGROUND: Surgical residency training has an extended tradition of long hours. Residency programs use a variety of call schedules to combat resident fatigue and sleep deprivation while maintaining adherence to duty hour restrictions. Nonetheless, there is a paucity of data regarding objective measurements of sleep during the different call schedules included in general surgery training. OBJECTIVE: The primary objective of this study was to compare the quantity of sleep in 24-hour time frames across all types of shifts worked by general surgery residents at our institution. The secondary objective was to measure activity level in total steps during various time frames. METHODS: This prospective observational study was performed between April 4 and August 26, 2018, with general surgery residents. Each resident was assigned a Fitbit Charge 2 to wear during all rotations, including general surgery and subspecialty services. RESULTS: Twenty-six out of 31 residents voluntarily participated in the study (84%). In-house call (IHC) had significantly less sleep in a 24-hour time frame than home call and night float (144 vs 283 vs 246 minutes, P < .001 and P < .028). IHC had significantly more steps than home call (11 245 vs 8756 steps, P = .039). The smallest number of steps was obtained when residents were not working (7904 steps). CONCLUSIONS: Our data demonstrate that surgical residents on IHC have significantly less sleep compared to all other types of on-call time frames. Residents on IHC have the most steps across all time frames.

Sumping's Up: A Multidisciplinary Educational Initiative on Gastric Drainage Tubes.

BACKGROUND: Nasogastric tube placement is widely taught, and tube maintenance relies on astute nursing care with adherence to both institutional and evidence-based recommendations. However, precise adherence to current recommendations relies on knowledge base regarding the identification of malfunctioning gastric drainage tubes. Troubleshooting skills are crucial in maintaining patient safety and recognizing malfunction. METHOD: Educational sessions on nasogastric and orogastric decompression tube management, led by a surgical intensive care fellow at a level 1 trauma center, were offered to critical care nurses. A presession and postsession survey evaluated the nurses' subjective and objective knowledge and comfort with naso/orogastric decompression tube management. RESULTS: Ninety-seven critical care RNs participated. For all questions, the proportion of correct answers significantly increased from presession survey to postsession survey (p < .001). Ninety-seven percent of all participants found the session to be very helpful. CONCLUSION: Physician-led educational sessions on naso/orogastric decompression tube management were well-received and improved subjective and objective measurements of nurses' knowledge and comfort level with gastric decompression tubes. [J Contin Educ Nurs. 2020;51(10):484-488.].

Predictors of hernia after loop ileostomy closure: a single-center retrospective review.

PURPOSE: Our aims were to determine the rate of incisional hernia after closure of a loop ileostomy (LI) and to identify any perioperative risk factors that may be associated with hernia development. METHODS: We performed an IRB-approved retrospective review that included consecutive patients who underwent LI closure from January 1, 2012, to December 31, 2014. The primary outcome was identification of hernia on physical exam or by abdominal imaging. A stepwise logistic regression analysis was used to determine predictors of ileostomy site hernia. RESULTS: A total of 243 consecutive patients had LI closure during the study timeframe. The overall rate of hernia formation was 11.9% (29/243). The median time to discovery of the hernia was 16.4 (range, 2.2-55.9) months with a median follow-up time of 49 months. Although LI performed in conjunction with sigmoidectomy for diverticulitis consisted of only 19% of ileostomy cases, 62% of hernias were (18/29) identified in this cohort. Rates of hernia formation increased with respect to body mass index (underweight 0%; normal 4.6%; overweight 13.8%; obese 21%). The multivariable model identified increased BMI (underweight/normal weight versus overweight: OR 4.13, 95% CI 1.06-16.04; underweight/normal weight versus obese: OR 8.74, 95% CI 2.17-35.23) and surgical indication (reference variable: diverticulitis; rectal cancer: OR 0.21, 95% CI 0.06-0.76; Crohn's/ulcerative colitis: OR 0.06, 95% CI 0.01-0.53; other: OR 0.15, 95% CI 0.04-0.64) as significant predictors of ileostomy site hernia. CONCLUSION: The development of a hernia at the site of LI closure was influenced mostly by BMI, surgical indication, and operative time.

Implementation of a Weekly Administrative Hour and the Impact on Case Logging and Duty Hour Reporting in Surgical Residents.

OBJECTIVE: To investigate the impact of a dedicated weekly administrative hour on case logging, duty hour reporting, and duty hour violations. DESIGN: Retrospective analyses of 2 timeframes pre-implementation and post-implementation of a dedicated weekly administrative hour in a surgical residency were assessed for changes in duty hour reporting, case logging, and duty hour violations. The preimplementation period spanned from July 2011 to June 2014 and the postimplementation period from July 2014 to June 2017. SETTING: Community-based, university-affiliated hospital. PARTICIPANTS: A total of 79 surgical residents were included over a 6-year period. The subjects worked before and after the implementation of a weekly dedicated administrative time. RESULTS: Seven and 30-day procedure logging rates improved from 28.7% to 37.2% and 52.7% to 69.9%, respectively (p < 0.001). PGY 1 residents showed a significant increase in procedures logged within 7 days during the postimplementation period. PGY 1, PGY 2 and PGY 3 all showed a significant increase in procedures logged within 30 days during the postimplementation period. Seven and 30-day duty hour completion rates increased postimplementation from 7.8% to 9.2% (p < 0.001) and 64.7% to 67.3% (p < 0.001), respectively. Duty hour violations decreased in the postimplementation time frame (40.6% vs 29.2%, p < 0.001). Duty hour violations were more common in earlier years of training. PGY 1 were 15.6 times more likely to have an 80 hours. per week violation than a PGY5 (OR: 15.1; 95% CI: 2.1-118.0). CONCLUSIONS: Procedural logging and duty hour compliance improved after implementation of a dedicated weekly time for administrative duties. The year of a resident in training is related to compliance with logging and may impact the incidence of duty hour violations. Residents reported significantly fewer duty hour violations, however this may be multifactorial.

What predicts successful nonoperative management with botulinum toxin for anal fissure?

BACKGROUND: Botulinum toxin has been established as a non-surgical alternative for chronic anal fissures. There is a paucity of data regarding which patients benefit most from this intervention. METHODS: We retrospectively collected data from all cases of chronic anal fissures treated with botulinum toxin over seven years to identify predictors of success. Non-responders were defined as any subsequent surgery or reporting satisfaction as poor or fair. RESULTS: Of 91 patients, 60% (n = 55) were responders and 26% (n = 25) underwent subsequent surgery. There were significantly more females among responders (78% vs. 55%, p = 0.02). A higher body mass index tended towards significance among non-responders (30 ± 7 vs. 27 ± 6, p = 0.08). High satisfaction at the first visit was associated with no subsequent surgery (18% vs. 45%, p = 0.002). CONCLUSIONS: Botulinum toxin can be successfully used to treat anal fissures in a majority of patients. Primary predictors of success were female sex, satisfaction at the first post-procedure visit and there was a tendency towards a lower body mass index.