Surgical residents on pediatric surgery rotations often have difficulty adjusting to decreased levels of autonomy. This study explores the reasons for and educational implications of this phenomenon. We performed 28 inte...Surgical residents on pediatric surgery rotations often have difficulty adjusting to decreased levels of autonomy. This study explores the reasons for and educational implications of this phenomenon. We performed 28 interviews with surgical residents and pediatric surgery attendings, fellows, and advanced practice providers from 16 institutions across the country and performed thematic analysis. Three themes emerged. First, perceptions of low autonomy are due to a high degree of supervision, which exists to ensure patient safety. Second, the need for increased supervision arises from numerous patient, surgeon, and resident factors specific to the pediatric surgical context. Third, educators and learners identified best practices to promote autonomy while maintaining safety. A shared understanding among surgical educators and learners about the factors which play into complex autonomy decisions and a common strategy to capitalize on appropriate learning opportunities may optimize resident training, both in pediatric surgery and other operative settings.
BACKGROUND: The COVID-19 pandemic had a profound impact on the social determinants of health. Previous studies documented changes in traumatic injury patterns during the early pandemic, but few studies examined the subse...BACKGROUND: The COVID-19 pandemic had a profound impact on the social determinants of health. Previous studies documented changes in traumatic injury patterns during the early pandemic, but few studies examined the subsequent months and years. METHODS: A retrospective comparative cohort study was conducted comparing trauma volumes, mechanisms, patient characteristics, and outcomes at a Level 1 trauma center in Vancouver, British Columbia prior to, during, and after the COVID-19 pandemic. RESULTS: Both during and after the pandemic, patients were younger, more male predominant, and presenting with higher proportions of deliberate self-harm and violence-related injuries. Younger patients were at increased odds of non-accidental injury. Male patients were at much greater risk of violence-related injury. Although proportions of trauma team activations increased, there was no statistical difference in ICU admissions, length of stay, or mortalities. CONCLUSION: The COVID-19 pandemic affected trauma presentations in B.C. not only during the pandemic, but also in the subsequent two years. Knowledge of these effects can better inform public health policy, injury prevention initiatives, and system-level performance improvement in healthcare delivery.
BACKGROUND: Preprocedural fasting guidelines have been in place in the US since 1999. Many studies show that patients actually fast longer than the guidelines recommend. OBJECTIVE: To perform a detailed review based on t...BACKGROUND: Preprocedural fasting guidelines have been in place in the US since 1999. Many studies show that patients actually fast longer than the guidelines recommend. OBJECTIVE: To perform a detailed review based on the reference lists from and citations to articles known to be relevant to the topic. A meta-analysis of the observed preprocedural fasting literature and the interventions intended to reduce fasting times was performed. METHODS: A literature search was performed on multiple databases using the search term preoperative fasting combined with other terms such as aspiration. Reference lists from articles reporting results of observed fasting times were reviewed and all relevant articles titles were entered into Google Scholar to find articles that referenced them. Meta-analyses of the results were reported as mean (±SD) differences along with the degree of heterogeneity between studies. The final search was completed on July 31, 2024. RESULTS: There were 79 articles of which 24 (44, 073 patients) reported pediatric and 31 (16, 039 patients) reported adult observed fasting times. There were 25 (76, 359 patients) articles reporting outcomes from interventions intended to reduce preprocedural fasting times. Because observed fasting times are measured in a relatively short period of time during which the patient is being managed by anesthesia, there was little risk for bias, missing data or problems of data integrity. Fasting duration from all the studies was considered high quality and all the quality assurance intervention studies were considered low quality. Mean observed pediatric fasting times for liquids was 7.1 h (95% CI: 5.7 to 8.5 h) and for solids it was 12.2 h (95% CI: 11.1 h, 13.2 h). Preprocedural liquid fasting times for adults were 10.3 h (95%CI: 9.3 h, 11.4 h) and 13.5 h (95% CI: 12.6 h, 14.3 h) for solids. Fasting times were reduced by QA interventions but not by patient education, change in hospital policy, staff education and text messaging. CONCLUSION: Despite 25 years of guidelines recommending limited preprocedural fasting, observed fasting durations remain very long and are refractory to most efforts intended to reduce them. REGISTRATION: OSF Tue Jun 14 2022 07:19:36 GMT-0700 https://osf.io/pdju4.
BACKGROUND: Given the interplay of cirrhosis with malignancy, management of hepatocellular carcinoma (HCC) relies on multidisciplinary clinician judgement to guide treatment. Accurate survival prediction would facilitate...BACKGROUND: Given the interplay of cirrhosis with malignancy, management of hepatocellular carcinoma (HCC) relies on multidisciplinary clinician judgement to guide treatment. Accurate survival prediction would facilitate decision-making and resource allocation while maintaining patient-centred care with optimized survival outcomes while avoiding futility, particularly regarding liver transplant. Machine learning may offer innovative support in clinical decision making. This systematic review is the first to our knowledge to summarize existing machine learning algorithms predicting survival in patients treated for HCC. METHODS: Studies describing a machine learning algorithm predicting survival in patients treated for HCC were included. Studies investigating only genetic or molecular factors, imaging, or disease recurrence were excluded. EMBASE, Medline and Web of Science were searched on December 4th, 2023. Included algorithms were analyzed based on input variables, sample size, algorithm type and performance as measured by the area under the receiver operating characteristic curve and concordance index. RESULTS: Twelve studies including 43 algorithms were included. The algorithm type, input variables and their selection method, sample size and performance varied widely. Algorithms did not perform differently based on sample size or number of variables. Algorithms using a gradient boosting algorithm tended to perform better across short- and long-term prediction. Short-term predictions tended to perform better than long-term predictions. The area under the receiver operating characteristic curves ranged from 0.66 to 0.92. CONCLUSION: Machine learning may offer an invaluable tool in survival prediction and individualized treatment in HCC. Existing algorithms show favourable, yet early, results. Standardized reporting, external validation and equity-focused model development are required before clinical implementation.
INTRODUCTION: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can offer a survival benefit for patients with peritoneal carcinomatosis (PC) of colorectal origin. This retrospective study e...INTRODUCTION: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can offer a survival benefit for patients with peritoneal carcinomatosis (PC) of colorectal origin. This retrospective study evaluated referral patterns for CRS-HIPEC in Alberta, Canada. METHODS: Patients with T4a/b colon cancer diagnosed between 2018 and 2023 who developed isolated PC were identified using the Alberta Cancer Registry (ACR). Medical records were reviewed to assess natural history after diagnosis. RESULTS: Of 791 patients with T4a/b colon cancer, 52 (6.57%) developed isolated PC, and 26 (50.0%) were referred for CRS-HIPEC. Referred patients had longer median overall survival (33.80 vs. 10.04 months, p<0.01), were younger (median age at diagnosis 56, vs 73 years, p < 0.01), and more likely to have received adjuvant systemic therapy (92.3% vs. 57.7%, p = 0.010). Of 26 non-referred patients, 10 (38.5%) had no clear contraindications to CRS-HIPEC CONCLUSION: Half of patients with PC of colorectal origin were not referred for CRS-HIPEC. Optimizing referral pathways may improve patient outcomes.
BACKGROUND: General surgery residents often experience burnout, which wellness initiatives may help mitigate. Descriptions of wellness initiatives on program websites may influence prospective applicants' decisions. This...BACKGROUND: General surgery residents often experience burnout, which wellness initiatives may help mitigate. Descriptions of wellness initiatives on program websites may influence prospective applicants' decisions. This study aimed to evaluate wellness content on general surgery residency websites in correlation with program characteristics. METHODS: Fellowship and Residency Electronic Interactive Database Access (FREIDA) was used to identify residency programs. Data included the program practice setting, size, and location. Program website wellness content was classified into a four-tier hierarchical system. RESULTS: 359 programs were identified with average program size 8.68 (SD = 6.05). Larger programs appeared in higher tiers. Significant differences in tier distribution were found across practice settings. Community/university-affiliated and university programs were more likely to be highly ranked. In the adjusted analysis, Southern and Western programs were predictive of higher tiers. CONCLUSIONS: Wellness advertisement on residency websites varies across programs. Standardizing the presentation of these initiatives could improve applicants' ability to assess programs.
BACKGROUND: This study assessed the quality, content, and readability of patient-centered online health information about diverticulitis. METHODS: Five common diverticulitis-related terms were searched on Google. The fir...BACKGROUND: This study assessed the quality, content, and readability of patient-centered online health information about diverticulitis. METHODS: Five common diverticulitis-related terms were searched on Google. The first 50 websites for each term were reviewed. Popularity, quality, core content, and readability were evaluated using Google Trends, the DISCERN instrument, core content domains based on American Society of Colon and Rectal Surgeons patient education, and an online readability calculator. RESULTS: Of 250 search results, 176 met inclusion criteria, yielding 98 unique websites. The median total DISCERN score was 48.5 ("fair"), and only 5.1% of websites were rated excellent. 73.5% exceeded the recommended eighth-grade reading level. More than 85% lacked information on recurrence risk or emerging research, and approximately 40% failed to describe diagnostic testing. CONCLUSIONS: Online health information on diverticulitis demonstrates considerable variability in content, quality and readability. To better support patient-centered care and informed decision-making, the development of accessible, high-quality online resources should be prioritized.
BACKGROUND: Severe obesity increases atrial fibrillation (AF) burden; whether prior metabolic surgery (MS) improves outcomes during AF hospitalization is uncertain. METHODS: Using a nationally representative database, we...BACKGROUND: Severe obesity increases atrial fibrillation (AF) burden; whether prior metabolic surgery (MS) improves outcomes during AF hospitalization is uncertain. METHODS: Using a nationally representative database, we queried all primary admissions for AF and severe obesity. Patients were propensity score matched and analyzed with survey-weighted regression analysis. RESULTS: Among 785,829 hospitalizations, 31,328 (4.0%) had prior MS. MS was associated with lower odds of mortality (AOR 0.60, 95% CI 0.48 - 0.76), acute kidney injury (AOR 0.72, 0.68 - 0.77), acute heart failure (AOR 0.76, 0.71 - 0.80), cardiogenic shock (AOR 0.50, 0.35 - 0.72), and non-home discharge (AOR 0.72, 0.67 - 0.77), with shorter LOS by 0.56 days and lower hospitalization costs by $885. CONCLUSIONS: Prior MS is associated with improved clinical outcomes and resource use during AF hospitalization.
Montanari E, Boccardi V, Semeraro E
… +10 more, Marano A, Santarelli M, Malerba S, Prete FP, Testini M, Girnyi S, Skokowski J, Schlögl M, Kristensen MT, Marano L
BACKGROUND: Chronological age is widely used to estimate surgical risk but may inadequately reflect early postoperative recovery. Markers of physiological reserve, including frailty and muscle strength, may better captur...BACKGROUND: Chronological age is widely used to estimate surgical risk but may inadequately reflect early postoperative recovery. Markers of physiological reserve, including frailty and muscle strength, may better capture vulnerability to surgical stress. METHODS: We conducted a prospective multicenter cohort study of 223 adults undergoing elective abdominal surgery. Frailty was assessed using a phenotype-based model, and handgrip strength (HGS) was measured at admission and discharge, with 90-day follow-up in a subset. Length of stay (LOS) and postoperative complications were analyzed using multivariable regression. RESULTS: Frailty independently predicted prolonged LOS and postoperative morbidity, whereas age did not. Oncologic surgery showed the strongest association with extended hospitalization. Higher preoperative HGS was independently associated with shorter LOS. Acute perioperative changes in HGS were not associated with outcomes. CONCLUSIONS: Early postoperative recovery appears more closely related to physiological reserve than to age.
BACKGROUND: Advanced practice providers (APPs) are essential to the surgical workforce, yet their roles, training, and drivers of satisfaction remain poorly understood. Identifying factors that support APP satisfaction i...BACKGROUND: Advanced practice providers (APPs) are essential to the surgical workforce, yet their roles, training, and drivers of satisfaction remain poorly understood. Identifying factors that support APP satisfaction is critical to workforce planning. METHODS: We conducted a cross-sectional survey (June 5-25, 2024) of surgical APPs at three U.S. academic medical centers. The primary outcome was overall job satisfaction; the primary independent variable was frequency of independent clinical decision-making. Multivariable ordinal logistic regression was performed. Secondary analyses assessed task preferences, perceived appropriateness of independent practice by task, and training experiences. RESULTS: Among 110 respondents, more frequent independent decision-making was associated with higher job satisfaction. APPs desired more procedural involvement and less documentation. Patient education, order entry, consenting, and documentation were commonly viewed as appropriate for independent practice. In-person and APP-specific training were rated most effective. Aligning responsibilities and training with APP preferences may improve satisfaction and workforce stability.