A Pilot Needs Assessment Addressing Gender-Based Microaggressions in Surgical Trainees.

BACKGROUND: Microaggressions result in the unintentional discrimination of marginalized groups. Female trainees are underrepresented in all levels of surgical training, thus, microaggressions are a salient topic for surgical education. This study aims to explore the perceived effect of gender-based microaggressions on surgical trainees. METHODS: After IRB approval, an anonymous Likert-scaled survey on perceptions of microaggressions was distributed to interns at our institution prior to starting surgical residency and one year after. Data was de-identified and analyzed using Likert analysis and Mann-Whitney U testing. Follow-up focus groups were lead and transcriptions analyzed using detailed thematic analysis. RESULTS: Sixty-nine of 104 interns (66%) responded to the initial survey, 34 (49%) were female. Nineteen of 38 interns (50%) responded to the follow-up survey, 10 (53%) were female. Compared to male repondents, females were significantly more likely to believe they were likely to experience microaggressions (median = 5, IQR 4-5 vs median = 4, IQR 3-4, p < 0.0001) and that microaggressions would impact their mental health (median = 4, IQR 4-4 vs median = 3, IQR 2-4, p < 0.0002). One-year follow-up data similarly revealed that, compared to male respondents, females were significantly more likely to have experienced microaggressions on a frequent basis throughout intern year (median = 3, IQR 3-3.75 vs median = 1.5, IQR 1-3, p < 0.05) and to have subjectively felt the impact of microaggressions on their mental health (median = 3, IQR 2.25-4 vs median = 1.5, IQR 1-2.25, p < 0.05). A focus group of female surgical trainees demonstrated patterns consistent with previously validated themes on gender-based microaggressions, including environmental invalidations, being treated as a second class citizen, and assumption of inferiority, at all levels of training. CONCLUSIONS: New trainees experience anxiety and lack preparedness when confronted with the threat of microaggressions. Our study reveals that female surgical interns are more likely than males to worry about microaggressions and to experience microaggressions and their negative effects. Focus group data exposes the wide-ranging impact of microaggressions experienced by female trainees of all levels. Thus, there should be benefit from instituting formal microaggression training prior to starting surgical residency.

Prescriptive Analytics Determining Which Patients Undergoing Simultaneous Liver-Kidney Transplant May Benefit From High-Risk Organs.

OBJECTIVES: Simultaneous liver-kidney transplant is a treatment option for patients with end-stage liver disease and concomitant irreversible kidney injury. We developed a decision toolto aid transplant programs to advise their candidates for simultaneous liver-kidney transplant on accepting high-risk grafts versus waiting for lower-risk grafts. MATERIALS AND METHODS: To find the critical decision factors, we used the prescriptive analytic technique of microsimulation.All probabilities used in the simulation model were calculated from Organ Procurement and Transplantation Network data collected from February 27, 2002 to June 30, 2018. RESULTS: The simulated patient population results revealed, on average, that high-risk candidates for simultaneous liver-kidney transplant who accept highrisk organs have 254.8 ± 225.4 weeks of life compared with 285.6 ± 232.4 weeks if they waited for better organs. However, critical decision factors included the specific organ offer rates within individual transplant programs and the rank of the candidate in each program's waitlist. Thus, for programs with lower organ offer rates or for candidates with a rare blood type, a high-risk simultaneous liver-kidney transplant candidate might accept a high-risk organ for longer survival. CONCLUSIONS: Our model can be utilized to determine when acceptance of high-risk organs for patients being considered for simultaneous liver-kidney transplant would lead to survival benefit, based on probabilities specific for their program.

Intraoperative consultation of vascular surgeons is increasing at a major American trauma center.

OBJECTIVE: Vascular surgeons are often called to aid other surgical specialties for complex exposure, hemorrhage control, or revascularization. The evolving role of the vascular surgeon in the management of intraoperative emergencies involving trauma patients remains undefined. The primary aims of this study included determining the prevalence of intraoperative vascular consultation in trauma, describing how these interactions have changed over time, and characterizing the outcomes achieved by vascular surgeons in these settings. We hypothesized that growing endovascular capabilities of vascular surgeons have resulted in an increased involvement of vascular surgery faculty in the management of the trauma patient over time. METHODS: A retrospective review of all operative cases at a single level I trauma center where a vascular surgeon was involved, but not listed as the primary surgeon, between 2002 and 2017 was performed. Cases were abstracted using Horizon Surgical Manager, a documentation system used in our operating room to track staff present, the type of case, and use. All elective cases were excluded. RESULTS: Of the 256 patients initially identified, 22 were excluded owing to the elective or joint nature of the procedure, leaving 234 emergent operative vascular consultations. Over the 15-year study period, a 529% increase in the number of vascular surgery consultations was seen, with 65% (n = 152) being intraoperative consultations requiring an immediate response. Trauma surgery (n = 103 [44%]) and orthopedic surgery (n = 94 [40%]) were the most common consulting specialties, with both demonstrating a trend of increasing consultations over time (general surgery, 1400%; orthopedic surgery, 220%). Indications for consultation were extremity malperfusion, hemorrhage, and concern for arterial injury. The average operative time for the vascular component of the procedures was 2.4 hours. Of patients presenting with ischemia, revascularization was successful in 94% (n = 116). Hemorrhage was controlled in 99% (n = 122). In-hospital mortality was relatively low at 7% (n = 17). Overall, despite the increase in intraoperative vascular consultations over time, a concomitant increase in the proportion of procedures done using endovascular techniques was not seen. CONCLUSIONS: Vascular surgeons are essential team members at a level I trauma center. Vascular consultation in this setting is often unplanned and often requires immediate intervention. The number of intraoperative vascular consultations is increasing and cannot be attributed solely to an increase in endovascular hemorrhage control, and instead may reflect the declining experience of trauma surgeons with vascular trauma. When consulted, vascular surgeons are effective in quickly gaining control of the situation to provide exposure, hemorrhage control, or revascularization.

A consensus statement for trauma surgery capacity building in Latin America.

BACKGROUND: Trauma is a significant public health problem in Latin America (LA), contributing to substantial death and disability in the region. Several LA countries have implemented trauma registries and injury surveillance systems. However, the region lacks an integrated trauma system. The consensus conference's goal was to integrate existing LA trauma data collection efforts into a regional trauma program and encourage the use of the data to inform health policy. METHODS: We created a consensus group of 25 experts in trauma and emergency care with previous data collection and injury surveillance experience in the LA. region. Experts participated in a consensus conference to discuss the state of trauma data collection in LA. We utilized the Delphi method to build consensus around strategic steps for trauma data management in the region. Consensus was defined as the agreement of ≥ 70% among the expert panel. RESULTS: The consensus conference determined that action was necessary from academic bodies, scientific societies, and ministries of health to encourage a culture of collection and use of health data in trauma. The panel developed a set of recommendations for these groups to encourage the development and use of robust trauma information systems in LA. Consensus was achieved in one Delphi round. CONCLUSIONS: The expert group successfully reached a consensus on recommendations to key stakeholders in trauma information systems in LA. These recommendations may be used to encourage capacity building in trauma research and trauma health policy in the region.

Effects of Gender Bias and Stereotypes in Surgical Training: A Randomized Clinical Trial.

Importance: Factors contributing to underrepresentation of women in surgery are incompletely understood. Pro-male bias and stereotype threat appear to contribute to gender imbalance in surgery. Objectives: To evaluate the association between pro-male gender bias and career engagement and the effect of stereotype threat on skill performance among trainees in academic surgery. Design, Setting, and Participants: A 2-phase study with a double-blind, randomized clinical trial component was conducted in 3 academic general surgery training programs. Residents were recruited between August 1 and August 15, 2018, and the study was completed at the end of that academic year. In phase 1, surveys administered 5 to 6 months apart investigated the association of gender bias with career engagement. In phase 2, residents were randomized 1:1 using permuted-block design stratified by site, training level, and gender to receive either a trigger of or protection against stereotype threat. Immediately after the interventions, residents completed the Fundamentals of Laparoscopic Surgery (FLS) assessment followed by a final survey. A total of 131 general surgery residents were recruited; of these 96 individuals with academic career interests met eligibility criteria; 86 residents completed phase 1. Eighty-five residents were randomized in phase 2, and 4 residents in each arm were lost to follow-up. Intervention: Residents read abstracts that either reported that women had worse laparoscopic skill performance than men (trigger of stereotype threat [A]) or had no difference in performance (protection against stereotype threat [B]). Main Outcomes and Measures: Association between perception of pro-male gender bias and career engagement survey scores (phase 1) and stereotype threat intervention and FLS scores (phase 2) were the outcomes. Intention-to-treat analysis was conducted. Results: Seventy-seven residents (38 women [49.4%]) completed both phases of the study. The association between pro-male gender bias and career engagement differed by gender (interaction coefficient, -1.19; 95% CI, -1.90 to -0.49; P = .02); higher perception of bias was associated with higher engagement among men (coefficient, 1.02; 95% CI, 0.19-2.24; P = .04), but no significant association was observed among women (coefficient, -0.25; 95% CI, -1.59 to 1.08; P = .50). There was no evidence of a difference in FLS score between interventions (mean [SD], A: 395 [150] vs B: 367 [157]; P = .51). The response to stereotype threat activation was similar in men and women (interaction coefficient, 15.1; 95% CI, -124.5 to 154.7; P = .39). The association between stereotype threat activation and FLS score differed by gender across levels of susceptibility to stereotype threat (interaction coefficient, -35.3; 95% CI, -47.0 to -23.6; P = .006). Higher susceptibility to stereotype threat was associated with lower FLS scores among women who received a stereotype threat trigger (coefficient, -43.4; 95% CI, -48.0 to -38.9; P = .001). Conclusions and Relevance: Perception of pro-male bias and gender stereotypes may influence career engagement and skill performance, respectively, among surgical trainees. Trial Registration: ClinicalTrials.gov Identifier: NCT03623009.

Limb Salvage Does Not Predict Functional Limb Outcome after Revascularization for Traumatic Acute Limb Ischemia.

BACKGROUND: Traumatic vascular injury leading to acute limb ischemia (ALI) is an uncommon problem with a potential for high morbidity. We describe a contemporary series of patients with traumatic ALI managed primarily by vascular surgeons at a tertiary referral center and review factors associated with limb salvage and functional limb outcomes. METHODS: We conducted a single institution, retrospective review of all patients requiring revascularization for upper extremity (UE) and lower extremity (LE) ALI secondary to trauma from 2013 to 2016. Demographic data, transfer timing, injury severity score (ISS), Rutherford classification (RC), preoperative imaging, level of occlusion, procedural information, fasciotomy characteristics, and discharge disposition were reviewed. Outcome measures included limb salvage and functional limb outcomes. RESULTS: We identified 68 patients with traumatic ALI requiring revascularization. The majority of patients had moderate ISS scores, were RC 2a or 2b on presentation (65%), were transferred from another institution (53%), and underwent preoperative imaging (62%) with expeditious time to operation (median 4.5 hr). The most common location of vascular injury for UE was axillary-brachial (88%) and for LE was femoral-popliteal (69%). Open vascular procedures dominated the treatment strategy, and the median number of operations was 3. Fasciotomy was performed in 25% of UE and 58% of LE injuries. Shunts were utilized in only 2 patients. Overall LS was 94% for UE and 78% for LE. The median length of stay (LOS) was 11 days, with 25% of patients discharged to a skilled nursing facility. Follow-up was obtained for 59% of patients. For UE injuries, 57% of patients had no or minimal functional deficits, while 33% had major functional deficits and 10% underwent amputation. For LE injuries, 68% of patients had no or minimal functional deficits, while 6% had major functional deficits, and 26% had undergone amputation. Rutherford class and the number of operations performed were independent predictors of amputation and functional limb at follow-up in our logistic regression model (P < 0.05). CONCLUSIONS: Revascularization for traumatic ALI yields high limb salvage rates in patients with RC 1 and 2 ischemia and patients with UE injuries. However, limb salvage does not necessarily equate to good functional outcomes. This signifies the complex nature of injuries in this patient population, especially when multiple operations are required.

Perceptions Regarding Mentorship Among General Surgery Trainees With Academic Career Intentions.

OBJECTIVE: Effective mentorship may be an opportunity to mitigate career de-prioritization, improve stress management, and bolster professional growth. Relatively few studies address specific challenges that occur for general surgery trainees. We conducted a focus group-based investigation to determine facilitators/barriers to effective mentorship among general surgery residents, who are intending to pursue an academic career. DESIGN: A semistructured focus group study was conducted to explore residents' attitudes and experiences regarding (1) needs for mentorship, (2) barriers to identifying mentors, and (3) characteristics of successful mentor-mentee interactions. Subjects self-identified and were characterized as either "Mentored" or "Nonmentored." Transcriptions were independently reviewed by 3 coders. Inter-rater reliability between the coders was evaluated by calculating Cohen's kappa for each coded item. SETTING: General surgery residents from 2 academic tertiary hospitals, University of Pittsburgh Medical Center, and University of Washington, participated. PARTICIPANTS: Thirty-four general surgery trainees were divided into 8 focus groups. RESULTS: There were no gender-based differences in mentoring needs among residents. Barriers to establishing a relationship with a mentor, such as lack of exposure to faculty, and time and determination on the part of both mentor and mentee, were exacerbated by aspects of surgical culture including gender dynamics, criticism, and hierarchy. Successful relationships between mentee and mentor were perceived to require personal/professional compatibility and a feeling that the mentor is invested in the mentee, while conflicts of interest and neglect detracted from a successful relationship. CONCLUSIONS: Our investigations demonstrate the importance of surgical hierarchy and culture in facilitating interpersonal interactions with potential mentors. Further studies will be necessary to determine how best to address these barriers.

Comparative analysis of gender differences in outcomes after trauma in India and the USA: case for standardised coding of injury mechanisms in trauma registries.

INTRODUCTION: While females generally have better outcomes than males after traumatic injury, higher mortality has been shown to occur in females after intentional trauma in lower-income countries. However, gender differences in trauma outcomes in different countries have not been previously compared. We conducted a two-country comparative analysis to characterise gender differences in mortality for different mechanisms of injury. METHODS: Two urban trauma databases were analysed from India and the USA for fall, motor vehicle collision (MVC) and assault patients between 2013 and 2015. Coarsened exact matching was used to match the two groups based on gender, age, injury severity score, Glasgow Coma Score and type of injury (blunt vs penetrating). The primary outcome of mortality was studied by using logistic regression to calculate the odds of death in the four country/gender subgroups. RESULTS: A total of 10 089 and 14 144 patients were included from the Indian and US databases, respectively. After matching on covariates, 7505 and 9448 patients were included in the logistic regression. Indian males had the highest odds of death compared with US males, US females and Indian females for falls, MVC and assaults. Indian females had over 7 times the odds of dying after falls, 5 times the odds of dying for MVC and 40 times the odds of dying after assaults when compared with US females. CONCLUSION: The high odds of death for Indian females compared with US females suggests that there are other injury and systemic factors that contribute to this discrepancy in mortality odds. This same mortality pattern and implication is seen for Indian males compared with all subgroups. Standardised coding of injury mechanism in trauma registries, in addition to intentionality of injury, can help further characterise discrepancies in outcomes by gender and country, to guide targeted injury prevention and care.

How can surgeons facilitate resident intraoperative decision-making?

BACKGROUND: Cognitive skills such as decision-making are critical to developing operative autonomy. We explored resident decision-making using a recollection of specific examples, from the attending surgeon and resident, after laparoscopic cholecystectomy. METHODS: In a separate semi-structured interview, the attending and resident both answered five questions, regarding the resident's operative roles and decisions, ways the attending helped, times when the attending operated, and the effect of the relationship between attending and resident. Themes were extracted using inductive methods. RESULTS: Thirty interviews were completed after 15 cases. Facilitators of decision-making included dialogue, safe struggle, and appreciation for retraction. Aberrant case characteristics, anatomic uncertainties, and time pressures provided barriers. Attending-resident mismatches included descriptions of transitioning control to the attending. CONCLUSIONS: Reciprocal dialogue, including concept-driven feedback, is helpful during intraoperative teaching. Unanticipated findings impede resident decision-making, and we describe differences in understanding transfers of operative control. Given these factors, we suggest that pre-operative discussions may be beneficial.

Outcomes of iliac vein stents after pregnancy.

OBJECTIVE: Stenting is the first-line treatment for obstructive iliocaval lesions when intervention is required. The aim of the study was to evaluate iliocaval stent patency during and after pregnancy in women of reproductive age who became pregnant after stent placement. METHODS: Female patients of reproductive age (18-45 years old) who underwent iliocaval stenting between May 2007 and March 2014 were identified from a three-center prospectively maintained database. Medical records were reviewed for demographics, baseline risk factors, operative data, and clinical follow-up to identify pregnancy and postpartum stent imaging. The primary end point was stent patency. Standard descriptive statistics were used. RESULTS: There were 310 women of reproductive age who received iliocaval stenting; 12 were identified to have had at least one pregnancy after stenting. The mean age was 28 ± 5 years. One patient received thrombolysis and stenting at 14 weeks of pregnancy for deep venous thrombosis (DVT) and May-Thurner syndrome, three for a previous postpartum DVT (2, 4, and 6 weeks postpartum), three for DVT before any pregnancy with a history of factor V Leiden, and the remaining five for unprovoked DVT. All stents were self-expanding with a diameter range of 14 to 16 mm. Mean time from stenting to pregnancy was 23.3 ± 28 months. All patients had patent stents during pregnancy and were prescribed therapeutic low-molecular-weight heparin by their obstetrician. One had asymptomatic left-sided stent compression 1 year after her second delivery, treated with balloon dilation. At average follow-up of 61 ± 56 months, all patients had patent stents with no ultrasound-identified structural damage or thrombosis. CONCLUSIONS: Pregnancy does not negatively affect the outcomes of iliocaval stents after lysis of DVT or May-Thurner syndrome. Iliocaval stenting is not contraindicated in women of reproductive age, although close clinical and ultrasound follow-up is warranted during and after pregnancy.

Prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery: a systematic review and meta-analysis.

BACKGROUND: Prophylactic mesh during laparotomy has been shown to be effective in preventing postoperative incisional hernia (IH) in high-risk patients. Since obesity is a risk factor for IH, we wished to determine whether mesh prevents IH in open and laparoscopic bariatric surgery patients. METHODS: We conducted a systematic review of the literature with meta-analysis. Seven studies met inclusion criteria. We abstracted data regarding postoperative IH development, surgical site infection, and seroma or wound leakage and performed meta-analysis. RESULTS: The prophylactic mesh group had significantly decreased odds of developing IH than the standard closure group (odds ratio, .30, 95% CI, .13 to .68, P = .004). No included studies evaluated outcomes after prophylactic mesh during laparoscopic bariatric surgery. CONCLUSIONS: Prophylactic mesh during open bariatric surgery appears to be beneficial in reducing postoperative IH without significant increasing the odds of surgical site infection or seroma or wound leakage. Higher quality studies, including those in laparoscopic patients, and cost-utility analysis, are needed to support routine use of this intervention.

Implementation of a Hospital Electronic Surgical Registry in a Lower-Middle-Income Country.

BACKGROUND: While the benefits of using electronic health records (EHRs) in both developed and low- and middle-income countries are known, the barriers to implementing EHRs in lower-middle-income countries have not been fully characterized. We assessed organizational readiness for implementation of a mobile (tablet-based) EHR, to create a real-time electronic surgical registry, in a busy lower-middle-income country hospital. METHODS: Six semi-structured focus groups were conducted with hospital administrators, faculty surgeons, surgical residents, interns, nurses and medical students in a large urban hospital in Asuncion, Paraguay. Focus groups were conducted over the course of three weeks during the pre-implementation phase to identify barriers to implementation. Focus group data were coded using the Theoretical Domains Framework (TDF), which are 12 validated domains related to behavior change. RESULTS: Reinforcement, environmental context/resources and roles/responsibilities were the most relevant TDF domains that emerged. Residents and students were more uncertain than faculty and department heads about who would enforce the use of the tool in place of paper charting. Internet quality was a concern raised by all. The local, normative hierarchical structure within the surgical department, including piecemeal communication between the department heads and the residents about roles and responsibilities, was a major perceived barrier to implementation. CONCLUSIONS: Uncertainties about reinforcement, roles and responsibilities for using a novel EHR tool, and technology infrastructure are potential barriers to address in the pre-implementation phase of introducing an EHR to a lower-middle-income country surgical service. Addressing these potential barriers with all stakeholders prior to implementation will be a critical next step in this effort.

Barriers to Long-Acting Reversible Contraceptive Uptake Among Homeless Young Women.

STUDY OBJECTIVE: To identify barriers to long-acting reversible contraception (LARC) uptake among homeless young women. DESIGN: In this mixed methods study surveys and guided interviews were used to explore women's contraceptive and reproductive experiences, interactions with the health care system, and their histories of homelessness. SETTING: All surveys and interviews were conducted at a homeless drop-in center or shelter. PARTICIPANTS: Fifteen women between 18 and 24 years of age with a past year history of homelessness. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Perceived barriers to contraceptive use, including knowledge and access barriers and interactions with the health care system around reproductive health. RESULTS: Confusion about the possibility of early termination of LARC, and the perception that providers deliberately withhold selective information about contraceptive options to bias contraceptive decision-making, were 2 key new findings. Women also reported interest in visual aids accompanying verbal contraceptive counseling. Pregnancy attitudes and history of reproductive and sexual coercion also influenced contraceptive decision-making and reported interest in LARC methods. CONCLUSION: Comprehensive counseling about all contraceptive options, including LARC, are important for targeting the perceived gaps in contraceptive education and care among homeless young women.