Association of Burnout and Other Factors Within Physicians and Advanced Practice Providers in an Academic Surgery Department.

BACKGROUND: Provider burnout is a work-related syndrome that is under-recognized, under-reported, and has negative repercussions on the individual, system, and patients. This study investigated burnout incidence and its association with wellness characteristics such as resilience, psychological safety, and perceptions of the workplace to inform future work in improving well-being. METHODS: Electronic surveys were sent to 153 physicians and advanced practice providers (APPs) in the department of surgery at a single institution. Survey topics included demographics, intention to stay, engagement, and items from validated measures for workplace perceptions including work pace/stress (Mini Z), burnout, psychological safety, and resilience. Descriptive statistics, bivariate associations, and logistic regression were used to evaluate responses. RESULTS: Overall response rate was 47%. The majority of providers reported feeling burned out (56%), and 48% indicated they would probably leave the organization within three years. Additionally, 61% reported being satisfied with their job and 55% felt that they contributed professionally in the ways they value most (meaningful work/engagement). Significant predictors for burnout included negative work environment perceptions (work pace/stress), low resilience, low meaningful work, and professional role (physician vs APP). DISCUSSION: Maintaining a healthy workforce requires investigation into the factors that support workplace well-being. The strongest predictors of burnout were work pace/stress. Protective factors against burnout were psychological safety and resilience. An organizational culture that promotes psychological safety, as well as workplace improvements to enhance providers' sense of meaning in work, and decreasing work pace and stress may contribute to the prevention of burnout and the retention.

Defining Types of Leadership Within an Academic Surgery Department to Promote Change for Decreasing Rates of Burnout.

OBJECTIVES: Successful leaders influence the group they represent. Effective surgical care is tied to its leadership climate. However, most surgical providers are not attuned to their individual strengths which if known they could leverage them within their teams. This study identifies leadership types within a department of surgery which may be used to better understand and cultivate their strengths. METHODS: In 2022, 172 providers in an academic surgery department were offered the GallupTM CliftonStrengths assessment, a proprietary instrument that maps 34 strengths across 4 domains of leadership. The assessment provides a respondent with their top 5 strengths and the domain in which they naturally "lead". RESULTS: Of 172 providers, 127 (74%) completed the assessment. While providers have strengths in multiple domains, they "lead with" a specific domain. Mapped from the providers' top 10 strengths, the most common "lead with" domain for surgical providers was Executing: the ability to implement ideas and produce results. Strategic Thinking: those who are analytical and push teams forward and Relationship Building: the ability to create strong and effective teams were followed by the least common domain. Influencing: the ability to communicate ideas and lead others. Formal leaders were significantly more likely to lead with Strategic Thinking. There were no significant differences between APPs and physicians. CONCLUSION: A majority of surgical providers "lead with" the GallupTM Executing domain. Those who lead with executing skills work tirelessly to produce outcomes. Learning to leverage the strengths of our teams to create cohesion and efficiency may improve engagement and retention.

Clinical Longevity of Preoperative Injection of Superparamagnetic Iron Oxide Nanoparticles for Delayed Sentinel Lymph Node Biopsy.

Diagnosis of ductal carcinoma in situ (DCIS) represents about 25% of newly diagnosed breast cancers. There is debate about the benefit of sentinel lymph node biopsy (SLNB) for further staging and guidance of therapy in patients with DCIS. Current guidelines recommend SLNB for patients undergoing breast-conserving therapy (BCT) for DCIS. Utilizing superparamagnetic iron oxide (SPIO) nanoparticles as a tracer may allow for a delayed SLNB (d-SLNB), typically within a month of injection. We present our experience with a patient who due to complications from surgery could not complete her d-SLNB for 165 days. The SPIO tracer remained active in the lymph node and remained clinically useful for this five and a half month gap from time of injection. Further study is needed to determine the clinical longevity of SPIO in a lymph node.

Metastatic Uterine Leiomyosarcoma presenting as small bowel intussusception at two independent visits.

•Metastatic disease to the small bowel may present with intussusception.•Clinical decision making for malignant bowel obstruction is difficult and individual specific.•Malignant bowel obstruction due to metastatic year has an average life expectancy of less than 200 days.

Unexpected Clinical Outcome for Myxoinflammatory Fibroblastic Sarcoma, When Should They Be Considered High Grade?

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare tumor of soft tissue. It typically presents as a low-grade sarcoma with myxoid stroma, has a predilection for distal extremities, and displays a high propensity for local recurrence, but low metastatic potential. The risk factors associated with high-risk lesions metastasizing are poorly defined. In cases where the tumor metastasizes, therapeutic options are few, and death is rare. Our case discusses an aggressive MIFS that progressed from a painless lesion on a patient's calf, to her death from a malignant pleural effusion within 21 months. The 58-year-old woman presented with a mass on her left calf. It was excised and was originally thought to be a benign process. It re-grew quickly after the initial resection, and she underwent re-excision of the mass. The pathologic examination was consistent with an MIFS. Despite negative margins on her second resection and an attempt at local control with radiotherapy, it metastasized to her lungs within less than 2 years. This resulted in a malignant pleural effusion that caused her death. An MIFS is typically benign but can metastasize in atypical cases. Even if the disease is metastatic, it is unlikely to be the cause of death. Treatment of metastatic MIFS is poorly defined, but there are suggested therapies beyond surgical resection and radiotherapy. Successful treatment of an MIFS should include a high index of suspicion in extremity lesions, screening for metastasis, and possible targeted therapies based on tumor genomics.

Race and Ethnicity Impacts Overall Survival of Patients with Appendiceal Cancer Who Undergo Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Appendiceal cancer treatment may include cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We investigated whether patient race/ethnicity influences outcomes and overall survival for patients with appendiceal cancer who undergo CRS/HIPEC. We queried the National Cancer Database for adult patients with appendiceal cancer treated with CRS/HIPEC from 2006 to 2018. Patients were stratified by race/ethnicity: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and Other. Sociodemographics and outcomes were compared using descriptive statistics. Kaplan-Meier survival analysis and Log-rank tests assessed differences in overall survival (OS). Cox Multivariate Regression evaluated factors associated with OS. In total, 2532 patients were identified: 2098 (82.9%) NHW, 186 (7.3%) NHB, 127 (5.0%) Hispanic, and 121 (4.8%) Other patients. The sociodemographics were statistically different across groups. The perioperative and postoperative outcomes were similar. OS was significantly different by race/ethnicity (p = 0.0029). NHB patients compared to Hispanic patients had the shortest median OS (106.7 vs. 145.9 months, p = 0.0093). Race/ethnicity was independently associated with OS: NHB (HR: 2.117 [1.306, 3.431], p = 0.0023) and NHW (HR: 1.549 [1.007, 2.383], p = 0.0463) patients compared to Hispanic patients had worse survival rates. Racial/ethnic disparities exist for patients with appendiceal cancer undergoing CRS/HIPEC. Despite having similar tumor and treatment characteristics, OS is associated with patient race/ethnicity.

Perforated Peptic Ulcer of the Duodenum After the Laparoscopic Roux-en-Y Gastric Bypass.

Perforated ulcers of the gastric remnant and duodenum seem to be a rare complication after a Roux-en-Y gastric bypass. Diagnosis of this complication can be difficult given a vague presentation, however, early intervention is critical to prevent further morbidity. We present the case of a 38-year-old male with a perforated duodenal ulcer nearly a year after Roux-en-Y gastric bypass. Upon presentation, he complained of 8 hours of epigastric pain. His medical history was significant for chronic peptic ulcer disease and a negative history of H. pylori. Recently, he had been prescribed naproxen by his primary care physician for knee pain. His vital signs were normal with the exception of his systolic blood pressure which was 190 mmHg. He was diaphoretic and peritonitic on exam. He was taken emergently for a diagnostic laparoscopy and found to have a perforation of ∼5 mm of the anterior portion of his duodenum. This was repaired laparoscopically with an omental patch and the patient recovered without any further intervention required. While this is a rare complication reported in the literature, this or similar complications of the remnant stomach may be underrepresented in publications. The surgical intervention of this disease will either be resection of the remnant or an omental patch. However, controversy remains as to the proper post-operative medical treatment. For our patient, the inciting agent was likely the naproxen he was given and this was stopped immediately. Patient education and ownership should remain a cornerstone for patients that have undergone a Roux-en-y gastric bypass.

Appendectomy for Vague Symptoms and Equivocal Physical Findings on Physical Exam and Computed Tomography.

Background: Appendicitis is a common condition affecting 7-8% of the general population. With the improvement of noninvasive imaging, the diagnostic approach and treatment algorithm for patients with clear signs and symptoms suggestive of acute appendicitis are well agreed-upon. However, patients without pathognomonic signs and symptoms, but with equivocal imaging pose a diagnostic dilemma. These patients may still have acute appendicitis and could potentially benefit from laparoscopic appendectomy. This may be especially true in the subset of patients with appendicoliths.Methods: Our case series exams a group of patients with atypical symptoms who eventually underwent appendectomy and were followed after surgery for at least a month. This case series consists of eight patients with abdominal pain accompanied by a variety of other signs and symptoms in addition to laboratory results and imagining characteristics which were nondiagnostic. These patients had initial Alvarado scores ranging from 0-6.Results: All of these patients were subsequently taken to the operating room for diagnostic laparoscopy and laparoscopic appendectomy. Of these patients, six were known to have appendicoliths based on computed tomography obtained during initial diagnostic workup.Conclusions: All patients underwent a diagnostic laparoscopy and appendectomy. Four had appendicitis and four also had resolution of their symptoms. There exist atypical presentations of appendiceal disease. Patients with abdominal pain/tenderness, even without diagnostic laboratory results or imaging characteristics, may benefit from laparoscopic appendectomy.

Ultramobile Surgical Set for Austere Damage Control Surgery.

The authors describe an equipment list for an ultramobile, surgeon-carried equipment set that is specifically designed for missions that require the extremes of constraints on personnel and resources conducted outside the ring of golden hour access to damage control surgery (DCS) capabilities.

ZIP8 is an iron and zinc transporter whose cell-surface expression is up-regulated by cellular iron loading.

ZIP8 (SLC39A8) belongs to the ZIP family of metal-ion transporters. Among the ZIP proteins, ZIP8 is most closely related to ZIP14, which can transport iron, zinc, manganese, and cadmium. Here we investigated the iron transport ability of ZIP8, its subcellular localization, pH dependence, and regulation by iron. Transfection of HEK 293T cells with ZIP8 cDNA enhanced the uptake of (59)Fe and (65)Zn by 200 and 40%, respectively, compared with controls. Excess iron inhibited the uptake of zinc and vice versa. In RNA-injected Xenopus oocytes, ZIP8-mediated (55)Fe(2+) transport was saturable (K(0.5) of ∼0.7 µm) and inhibited by zinc. ZIP8 also mediated the uptake of (109)Cd(2+), (57)Co(2+), (65)Zn(2+) > (54)Mn(2+), but not (64)Cu (I or II). By using immunofluorescence analysis, we found that ZIP8 expressed in HEK 293T cells localized to the plasma membrane and partially in early endosomes. Iron loading increased total and cell-surface levels of ZIP8 in H4IIE rat hepatoma cells. We also determined by using site-directed mutagenesis that asparagine residues 40, 88, and 96 of rat ZIP8 are glycosylated and that N-glycosylation is not required for iron or zinc transport. Analysis of 20 different human tissues revealed abundant ZIP8 expression in lung and placenta and showed that its expression profile differs markedly from ZIP14, suggesting nonredundant functions. Suppression of endogenous ZIP8 expression in BeWo cells, a placental cell line, reduced iron uptake by ∼40%, suggesting that ZIP8 participates in placental iron transport. Collectively, these data identify ZIP8 as an iron transport protein that may function in iron metabolism.

Zip14 is a complex broad-scope metal-ion transporter whose functional properties support roles in the cellular uptake of zinc and nontransferrin-bound iron.

Recent studies have shown that overexpression of the transmembrane protein Zrt- and Irt-like protein 14 (Zip14) stimulates the cellular uptake of zinc and nontransferrin-bound iron (NTBI). Here, we directly tested the hypothesis that Zip14 transports free zinc, iron, and other metal ions by using the Xenopus laevis oocyte heterologous expression system, and use of this approach also allowed us to characterize the functional properties of Zip14. Expression of mouse Zip14 in RNA-injected oocytes stimulated the uptake of (55)Fe in the presence of l-ascorbate but not nitrilotriacetic acid, indicating that Zip14 is an iron transporter specific for ferrous ion (Fe(2+)) over ferric ion (Fe(3+)). Zip14-mediated (55)Fe(2+) uptake was saturable (K(0.5) ≈ 2 µM), temperature-dependent (apparent activation energy, E(a) = 15 kcal/mol), pH-sensitive, Ca(2+)-dependent, and inhibited by Co(2+), Mn(2+), and Zn(2+). HCO(3)(-) stimulated (55)Fe(2+) transport. These properties are in close agreement with those of NTBI uptake in the perfused rat liver and in isolated hepatocytes reported in the literature. Zip14 also mediated the uptake of (109)Cd(2+), (54)Mn(2+), and (65)Zn(2+) but not (64)Cu (I or II). (65)Zn(2+) uptake also was saturable (K(0.5) ≈ 2 µM) but, notably, the metal-ion inhibition profile and Ca(2+) dependence of Zn(2+) transport differed from those of Fe(2+) transport, and we propose a model to account for these observations. Our data reveal that Zip14 is a complex, broad-scope metal-ion transporter. Whereas zinc appears to be a preferred substrate under normal conditions, we found that Zip14 is capable of mediating cellular uptake of NTBI characteristic of iron-overload conditions.

Six-minute walk test and health status assessment in sarcoidosis.

BACKGROUND: The 6-min walk test has proved useful in assessing impairment and prognosis in various lung diseases. METHODS: A prospective study of 142 sarcoidosis patients seen during a 6-week period at one tertiary sarcoidosis clinic. All patients completed spirometry, 6-min walk testing, St. George Respiratory Questionnaire (SGRQ), fatigue assessment scale, and dyspnea score. Parameters assessed included the 6-min walk distance (6MWD) and the initial and lowest oxygen saturations during the test. RESULTS: One hundred three of 142 patients had extrapulmonary manifestations, 10 patients had left ventricular dysfunction, and 14 patients had documented pulmonary hypertension. Seventy-three patients (51%) completed a 6MWD < 400 m, and 32 patients (22%) walked < 300 m. The 14 patients with documented pulmonary hypertension had a shorter 6MWD (median, 280 m; range, 61 to 404) than those without documented pulmonary arterial hypertension (median, 411 m; range, 46 to 747; p < 0.0001). Several components of the pulmonary function and quality of life correlated with 6MWD. Using a stepwise multiple regression analysis, only SGRQ activity component (t = - 7.498, p < 0.0001), FVC (t = 4.415, p < 0.0001), and lowest oxygen saturation (t = 2.55, p < 0.02) were independent predictors of 6MWD. CONCLUSIONS: 6MWD was reduced in the majority of sarcoidosis patients. Several factors were associated with a reduced 6MWD, including FVC, oxygen saturation with exercise, and self-reported respiratory health. Both 6MWD and quality of life measures are useful in assessing the functional status of sarcoidosis patients.