Association Between Anesthesiologist Sex and Patients' Postoperative Outcomes: A Population-based Cohort Study.

OBJECTIVE: To examine the association of anesthesiologist sex on postoperative outcomes. BACKGROUND: Differences in patient postoperative outcomes exist, depending on whether the primary surgeon is male or female, with better outcomes seen among patients treated by female surgeons. Whether the intraoperative anesthesiologist's sex is associated with differential postoperative patient outcomes is unknown. METHODS: We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007 to 2019 in Ontario, Canada. We assessed the association between the sex of the intraoperative anesthesiologist and the primary end point of the adverse postoperative outcome, defined as death, readmission, or complication within 30 days after surgery, using generalized estimating equations. RESULTS: Among 1,165,711 patients treated by 3006 surgeons and 1477 anesthesiologists, 311,822 (26.7%) received care from a female anesthesiologist and 853,889 (73.3%) from a male anesthesiologist. Overall, 10.8% of patients experienced one or more adverse postoperative outcomes, of whom 1.1% died. Multivariable adjusted rates of the composite primary end point were higher among patients treated by male anesthesiologists (10.6%) compared with female anesthesiologists (10.4%; adjusted odds ratio 1.02, 95% CI: 1.00-1.05, P =0.048). CONCLUSIONS: We demonstrated a significant association between sex of the intraoperative anesthesiologist and patient short-term outcomes after surgery in a large cohort study. This study supports the growing literature of improved patient outcomes among female practitioners. The underlying mechanisms of why outcomes differ between male and female physicians remain elusive and require further in-depth study.

Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures.

Importance: Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex. Objective: To examine the association between surgeon sex and health care costs among patients undergoing surgery. Design, Setting, and Participants: This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023. Exposure: Surgeon sex. Main Outcome and Measure: The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates. Results: Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202). Conclusions and Relevance: This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries.

Importance: Sex- and gender-based differences in a surgeon's medical practice and communication may be factors in patients' perioperative outcomes. Patients treated by female surgeons have improved 30-day outcomes. However, whether these outcomes persist over longer follow-up has not been assessed. Objective: To examine whether surgeon sex is associated with 90-day and 1-year outcomes among patients undergoing common surgeries. Design, Setting, and Participants: A population-based retrospective cohort study was conducted in adults in Ontario, Canada, undergoing 1 of 25 common elective or emergent surgeries between January 1, 2007, and December 31, 2019. Analysis was performed between July 15 and October 20, 2022. Exposure: Surgeon sex. Main Outcomes and Measures: An adverse postoperative event, defined as the composite of death, readmission, or complication, was assessed at 90 days and 1 year following surgery. Secondarily, each of these outcomes was assessed individually. Outcomes were compared between patients treated by female and male surgeons using generalized estimating equations with clustering at the level of the surgical procedure, accounting for patient-, procedure-, surgeon-, anesthesiologist-, and facility-level covariates. Results: Among 1 165 711 included patients, 151 054 were treated by a female and 1 014 657 by a male surgeon. Overall, 14.3% of the patients had 1 or more adverse postoperative outcomes at 90 days and 25.0% had 1 or more adverse postoperative outcomes 1 year following surgery. Among these, 2.0% of patients died within 90 days and 4.3% died within 1 year. Multivariable-adjusted rates of the composite end point were higher among patients treated by male than female surgeons at both 90 days (13.9% vs 12.5%; adjusted odds ratio [AOR], 1.08; 95% CI, 1.03-1.13) and 1 year (25.0% vs 20.7%; AOR, 1.06; 95% CI, 1.01-1.12). Similar patterns were observed for mortality at 90 days (0.8% vs 0.5%; AOR 1.25; 95% CI, 1.12-1.39) and 1 year (2.4% vs 1.6%; AOR, 1.24; 95% CI, 1.13-1.36). Conclusions and Relevance: After accounting for patient, procedure, surgeon, anesthesiologist, and hospital characteristics, the findings of this cohort study suggest that patients treated by female surgeons have lower rates of adverse postoperative outcomes including death at 90 days and 1 year after surgery compared with those treated by male surgeons. These findings further support differences in patient outcomes based on physician sex that warrant deeper study regarding underlying causes and potential solutions.

Robotic Versus Open Cystectomy for Bladder Cancer: Synthesizing the Data from Current Systematic Reviews and Meta-Analyses.

This is a summary of existing systematic reviews comparing robotic assisted radical cystectomy (RARC) with open radical cystectomy (ORC). Our aim was to compare operative approaches with respect to perioperative, postoperative, oncologic, and health-related quality of life (QOL) outcomes. We performed a systematic review of MEDLINE, Medline-in-Process and Medline Epubs Ahead of Print, and the Cochrane Library on 22 February 2022. We included reviews of adult patients with bladder cancer undergoing RARC or ORC for muscle invasive or high-risk non-muscle invasive bladder cancer. Nonrandomized studies were excluded to minimize confounding and selection bias. The GRADE approach was used to determine the confidence in estimates. We assessed the quality of identified systematic reviews using AMSTAR 2 checklist. Six well-conducted, systematic reviews and meta-analyses were included. RARC was consistently associated with lower estimated blood loss (EBL) and transfusion rates, and longer operative time. There was inconsistent evidence for the impact of RARC on hospital length of stay (LOS). There was no significant difference in overall complication rate or major complication rate, or oncologic outcomes between groups. Comparison of QOL outcomes between studies was limited by statistical and methodological heterogeneity. RARC is associated with improvement in EBL and transfusion risk. There does not appear to be differences in oncologic outcomes or complications between approaches. Prospective studies are needed to assess the impact of diversion type, technique, and recovery pathways on patient outcomes and to assess the impact of operative approach on cost and patient-reported QOL.

Controversies associated with ureteral access sheath placement during ureteroscopy.

The use of ureteral access sheaths (UAS) is common practice during routine flexible ureteroscopy procedures. However, debates and concerns continue amongst endourologists on routine UAS placement. UAS placement allows for multiple passages of the ureteroscope, decreases intrarenal pressure, and may improve stone-free rates. However, concerns for the UAS's effectiveness in these claimed benefits and complications related to UAS placement has been documented and investigated by many. In this review, we will discuss the controversies surrounding the placement of UAS during ureteroscopy.

Radical cystectomy: a review of techniques, developments and controversies.

Radical cystectomy (RC) with urinary diversion is considered the standard treatment for muscle invasive bladder cancer (MIBC). As one of the most challenging surgical techniques performed by urologists, RC was described many decades ago, and yet patient morbidity rates have remained stagnant over the years. This review outlines the most recent indications and techniques for RC and analyses the current landscape of complications after cystectomy. There is significant room for improvement with respect to both oncologic and functional outcomes after RC. Future efforts will need to focus on unifying reporting methodology, optimal patient selection criteria, enhanced surgical techniques and peri-operative care pathways, and technological advances to improve patient outcomes.

Updating the Canadian obesity maps: an epidemic in progress.

OBJECTIVES: Obesity is a growing problem in Canada and worldwide. While obesity maps that convey changing rates over time and geography provide a useful way to convey such information, regional obesity surveillance maps for Canada have not been published since 1998. This research provides a summary of changing Canadian obesity rates since that time. METHODS: We computed estimated obesity rates for provinces and territories across Canada from 2000 to 2011. Data were based on Canadian Community Health Survey and corrected for self-report bias. Data reporting the estimated percent of the adult population who are obese were mapped over time overall and by sex according to Canadian province and territory. RESULTS: The data indicate that the estimated prevalence of obesity across Canada has continued to increase over the past 11 years. Current rates exceed 30% in the Maritime provinces (Newfoundland, New Brunswick, Nova Scotia, Prince Edward Island) and in two territories (Northwest Territory, Nunavut). Data for men and women are generally consistent. The major increase in obesity appears to have occurred in the first part of this period, with relatively stable rates found from 2008 to 2011. However, obesity rates are still climbing, warranting continued surveillance efforts. CONCLUSION: Maps showing changing regional obesity rates provide a compelling pan-Canadian portrait that can lead to an impetus for action for the public, health care providers, and decision makers. Such colour-coded maps offer an efficient way to convey complex data that transcends language differences and personalizes the data for the viewer.

Targeted mini-strokes produce changes in interhemispheric sensory signal processing that are indicative of disinhibition within minutes.

Most processing of sensation involves the cortical hemisphere opposite (contralateral) to the stimulated limb. Stroke patients can exhibit changes in the interhemispheric balance of sensory signal processing. It is unclear whether these changes are the result of poststroke rewiring and experience, or whether they could result from the immediate effect of circuit loss. We evaluated the effect of mini-strokes over short timescales (<2 h) where cortical rewiring is unlikely by monitoring sensory-evoked activity throughout much of both cortical hemispheres using voltage-sensitive dye imaging. Blockade of a single pial arteriole within the C57BL6J mouse forelimb somatosensory cortex reduced the response evoked by stimulation of the limb contralateral to the stroke. However, after stroke, the ipsilateral (uncrossed) forelimb response within the unaffected hemisphere was spared and became independent of the contralateral forelimb cortex. Within the unaffected hemisphere, mini-strokes in the opposite hemisphere significantly enhanced sensory responses produced by stimulation of either contralateral or ipsilateral pathways within 30-50 min of stroke onset. Stroke-induced enhancement of responses within the spared hemisphere was not reproduced by inhibition of either cortex or thalamus using pharmacological agents in nonischemic animals. I/LnJ acallosal mice showed similar rapid interhemispheric redistribution of sensory processing after stroke, suggesting that subcortical connections and not transcallosal projections were mediating the novel activation patterns. Thalamic inactivation before stroke prevented the bilateral rearrangement of sensory responses. These findings suggest that acute stroke, and not merely loss of activity, activates unique pathways that can rapidly redistribute function within the spared cortical hemisphere.

In vivo voltage-sensitive dye imaging in adult mice reveals that somatosensory maps lost to stroke are replaced over weeks by new structural and functional circuits with prolonged modes of activation within both the peri-infarct zone and distant sites.

After brain damage such as stroke, topographically organized sensory and motor cortical representations remap onto adjacent surviving tissues. It is conceivable that cortical remapping is accomplished by changes in the temporal precision of sensory processing and regional connectivity in the cortex. To understand how the adult cortex remaps and processes sensory signals during stroke recovery, we performed in vivo imaging of sensory-evoked changes in membrane potential, as well as multiphoton imaging of dendrite structure and tract tracing. In control mice, forelimb stimulation evoked a brief depolarization in forelimb cortex that quickly propagated to, and dissipated within, adjacent motor/hindlimb areas (<100 ms). One week after forelimb cortex stroke, the cortex was virtually unresponsive to tactile forelimb stimulation. After 8 weeks recovery, forelimb-evoked depolarizations reemerged with a characteristic pattern in which responses began within surviving portions of forelimb cortex (<20 ms after stimulation) and then spread horizontally into neighboring peri-infarct motor/hindlimb areas in which depolarization persisted 300-400% longer than controls. These uncharacteristically prolonged responses were not limited to the remapped peri-infarct zone and included distant posteromedial retrosplenial cortex, millimeters from the stroke. Structurally, the remapped peri-infarct area selectively exhibited high levels of dendritic spine turnover, shared more connections with retrosplenial cortex and striatum, and lost inputs from lateral somatosensory cortical regions. Our findings demonstrate that sensory remapping during stroke recovery is accompanied by the development of prolonged sensory responses and new structural circuits in both the peri-infarct zone as well as more distant sites.