Championing Civility in the Clinical Learning Environment: Evaluation of a Novel Training Program.

PROBLEM: Incivility in the health care workplace is increasing and negatively impacts everyone in the environment, including health care team members and the patients and families they serve. This study examined the efficacy and impact of Civility Champions (CCs), a novel training program for a multidisciplinary cohort of faculty and graduate medical education (GME) trainees based in principles of trauma-informed care, nonviolent communication, and restorative practices. APPROACH: Participants were 39 faculty and GME trainees representing 6 departments in a major academic medical center. The concurrent, mixed-methods study employed the Kirkpatrick New World Model as a framework for the creation of the evaluation tools as well as to analyze and report the results of the study. Quantitative and qualitative data analysis examined participants' reactions, perceived learning, workplace use of the skills following training, and initial indicators of whether the program is on track to meet its goals. OUTCOMES: Participants found CCs training to be valuable (84.6% agree or strongly agree that training was relevant and would recommend it to others). Post-training, CCs felt an increased sense of confidence and commitment using the skills and knowledge learned as indicated by a positive average change score (P < .05) on all measures. At the 6-month survey, 70% of CCs had employed the skills. Results on the implementation of the CCs program found that key success factors include improving program visibility, providing opportunities for skill refreshment, and fostering a supportive community. NEXT STEPS: This study expanded a novel training program to multidisciplinary departments and provided early evaluation of the efficacy of the training in the health care workplace. CCs training showed significant measurable benefit using both quantitative and qualitative measures. Future iterations will include training interdisciplinary cohorts and will attempt to assess the program's impact on institutional culture.

Maternal morbidity in postpartum severe preeclampsia by obstetric delivery volume.

BACKGROUND: Pre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings. OBJECTIVES: We investigated the relationship between facility delivery volume and rates of non-transfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features. STUDY DESIGN: This is a retrospective cohort study using the Nationwide Readmissions Database (2015-2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was non-transfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and non-transfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, non-transfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery. RESULTS: The cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25th percentile-75th percentile: 2.2-6.5). Non-transfusion SMM occurred in 7% of patients readmitted to facilities with >2,000 deliveries compared to 9% with 1-2,000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1,000 deliveries, the odds of a non-transfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99) CONCLUSIONS: Non-transfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.

Success Rates with Preimplantation Genetic Testing for Aneuploidy (PGT-A) in Good Prognosis Patients is Dependent on Age.

OBJECTIVE: To evaluate cumulative live birth following preimplantation genetic testing for aneuploidy (PGT-A) with next generation sequencing (NGS) compared to morphology alone among patients aged 21-40 years undergoing single blastocyst transfer. DESIGN: Retrospective cohort study SUBJECTS: Patients aged 21 to 40 years undergoing first, autologous retrieval cycles resulting in ≥ 5 fertilized oocytes, with subsequent single blastocyst transfer in SART clinics from 2016 to 2019. EXPOSURE: PGT-A using NGS MAIN OUTCOME MEASURES: The primary outcome was cumulative live birth per retrieval. Secondary outcomes included clinical pregnancy, miscarriage, and live birth per transfer. RESULTS: A total of 56,469 retrieval cycles were included in the analysis. Retrieval cycles were stratified based on age (< 35, 35-37, and 38-40 years) and exposure to PGT-A with NGS. Modified Poisson regression modeling was used to evaluate the association between PGT-A and cumulative live birth per retrieval while controlling for covariates. In this cohort, most cycles did not utilize PGT-A (n=49,608; 88%). After adjusting for covariates, the use of PGT-A was associated with a slightly lower cumulative live birth in individuals aged <35 years (risk ratio [RR] 0.96; 95% CI: 0.93, 0.99) compared with no PGT, but higher cumulative live birth in ages 35-37 years (RR 1.04; 95% CI: 1.00, 1.08), and 38-40 years (RR 1.14; 95% CI: 1.07, 1.20). A subgroup analysis limited to freeze-all cycles (n=29,041) showed that PGT-A was associated with higher cumulative live birth in individuals aged ≥ 35 years and was similar to no PGT in individuals aged < 35 years. Miscarriage was significantly less likely in individuals aged ≥ 35 years utilizing PGT-A compared with no PGT-A. CONCLUSION: In this large national database study, success rates in cycles utilizing PGT-A were dependent on age. Cumulative live birth was observed to be significantly less likely in PGT-A cycles among individuals aged < 35 years and more likely among individuals aged 38 to 40 years, compared to no PGT-A. In individuals with no fresh transfer, results were similar. Moreover, miscarriage was significantly less likely with PGT-A among individuals aged 35-40 years in a subgroup analysis of freeze-all cycles.

A guide to successful management of collaborative partnerships in quantitative research: An illustration of the science of team science.

Data-intensive research continues to expand with the goal of improving healthcare delivery, clinical decision-making, and patient outcomes. Quantitative scientists, such as biostatisticians, epidemiologists, and informaticists, are tasked with turning data into health knowledge. In academic health centres, quantitative scientists are critical to the missions of biomedical discovery and improvement of health. Many academic health centres have developed centralized Quantitative Science Units which foster dual goals of professional development of quantitative scientists and producing high quality, reproducible domain research. Such units then develop teams of quantitative scientists who can collaborate with researchers. However, existing literature does not provide guidance on how such teams are formed or how to manage and sustain them. Leaders of Quantitative Science Units across six institutions formed a working group to examine common practices and tools that can serve as best practices for Quantitative Science Units that wish to achieve these dual goals through building long-term partnerships with researchers. The results of this working group are presented to provide tools and guidance for Quantitative Science Units challenged with developing, managing, and evaluating Quantitative Science Teams. This guidance aims to help Quantitative Science Units effectively participate in and enhance the research that is conducted throughout the academic health centre-shaping their resources to fit evolving research needs.

The Earlier the Better: Surgical Stabilization of Rib Fractures Associated With Improved Outcomes.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) has been associated with lower rates of mortality and fewer respiratory complications. This study sought to evaluate the association between SSRF timing and patient outcomes. METHODS: This retrospective analysis included patients aged ≥45 y who underwent SSRF in the Trauma Quality Improvement Program database from 2016 to 2020. Primary outcome was incidence of ventilator-assisted pneumonia (VAP). Secondary outcomes included acute respiratory distress syndrome (ARDS), unplanned endotracheal intubation, in-hospital mortality, failure to rescue (FTR) after all major complications, and FTR after severe respiratory complications. Logistic regression models of outcomes on timing to SSRF were fit while controlling for age, gender, body mass index, injury severity score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS: Among 4667 patients who received SSRF, average time to SSRF was 4.6 ± 3.2 d. Each additional day to SSRF was associated with increased odds of VAP (odds ratio [OR] 1.07, confidence interval [CI] 1.03-1.11) and intubation (OR 1.10, CI 1.08-1.13). A longer time to SSRF was associated with increased odds of ARDS (OR 1.10, CI 1.05-1.15), while no significant association was observed for in-hospital mortality (OR 0.99, CI 0.93-1.04). A longer time to SSRF was associated with decreased odds of FTR after a major complication (OR 0.90, CI 0.83-0.97) and respiratory complications (OR 0.87, CI 0.78-0.96). CONCLUSIONS: For each day that SSRF is delayed, increased odds of VAP, intubation, and ARDS were observed. Prompt intervention is crucial for preventing these complications and improving our ability to rescue patients.

Development, Implementation, and Assessment of an Online Modular Telehealth Curriculum for Health Professions Students.

Purpose: Several national health profession organizations endorse or have developed competencies for telehealth, yet there is no standardized curriculum for teaching telehealth to health professions students. Additionally, implementing telehealth curricula is challenging due to limited curricular space and differing needs of various health profession programs. We describe the development, implementation, and pilot assessment of an online, modular telehealth curriculum for health professions students. Methods: An online, modular telehealth curriculum for health professions students was developed in 2021-2022. Nine modules were created, focusing on the logistics of performing a telehealth visit and system-based virtual assessments. In academic year 2022-2023, course directors from the Duke doctor of medicine (MD), physician assistant (PA), and nurse practitioner (NP) programs utilized modules in their courses. For modules taken, students were surveyed and self-assessed their confidence, knowledge gained, and likelihood of utilizing the telehealth skills taught in the module(s). Results: During the 2022-2023 academic year, MD, NP, and PA students at Duke participated in one or more of the telehealth modules in an existing course. The median responses to self-assessed confidence questions for all health profession students to be in the "moderately" or "very confident" range. Similarly, students reported a median response of "moderate knowledge gained" for each module taken. NP students reported slightly lower levels of confidence and likelihood of utilizing telehealth skills than other professions. No other significant differences in the remainder of responses were observed between health professions. Conclusion: Exposure of health professions students to telehealth through utilization of online, interactive modules may result in increased telehealth skill confidence and knowledge, and furthermore, a belief that they will utilize these skills in future practice. Larger scale implementation of the telehealth curriculum and development of outcome measures which assess clinical application of skills conveyed will provide more information about the efficacy of the curriculum.

Age-Neutral Surgical Stabilization of Rib Fractures: Breaking the Ageism Barrier.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes. METHODS: This retrospective analysis included patients ≥45 y old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016 to 2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45-64 and 65+. Outcomes included ventilator-associated pneumonia, unplanned endotracheal intubation, acute respiratory distress syndrome, in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, body mass index, Injury Severity Score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS: Two thousand eight hundred thirty-nine patients aged 45-64 and 1828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with ventilator-associated pneumonia, unplanned intubation, acute respiratory distress syndrome, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (P > 0.05). Black (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.59-0.77; P < 0.001), Hispanic (OR 0.80; 95% CI: 0.71-0.91; P < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76-0.95; P = 0.005) patients were less likely to receive SSRF. CONCLUSIONS: No differences in clinical outcomes were measured between adults aged 45-64 and ≥65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.

Positive Outliers: A Mixed Methods Study of Resiliency to Childhood Obesity in High-Risk Neighborhoods.

OBJECTIVE: Despite the high prevalence of obesity and the clustering of risk by neighborhood, few studies have examined characteristics which promote healthy child weight in neighborhoods with high obesity risk. We aimed to identify protective factors for children living in neighborhoods with high obesity risk. METHODS: We identified neighborhoods with high obesity risk using geolocated electronic health record data with measured body mass index (BMI) from well-child visits (2012-2017). We then recruited caregivers with children aged 5 to 13 years who lived in census tracts with mean child BMI percentile ≥72 (February 2020-August 2021). We used sequential mixed methods (quantitative surveys, qualitative interviews) to compare individual, interpersonal, and perceived neighborhood factors among families with children at a healthy weight (positive outliers [PO]) versus families with ≥1 child with overweight or obesity (controls). Regression models and comparative qualitative analysis were used to identify protective characteristics. RESULTS: Seventy-three caregivers participated in the quantitative phase (41% PO; 34% preferred Spanish) and twenty in the qualitative phase (50% PO; 50% preferred Spanish). The frequency of healthy caregiver behaviors was associated with being a PO (Family Health Behavior Scale Parent Score adjusted ß 3.67; 95% CI 0.52-6.81 and qualitative data). Protective factors also included caregivers' ability to minimize the negative health influences of family members and adhere to family routines. CONCLUSIONS: There were few differences between PO and control families. Support for caregiver healthy habits and adherence to healthy family routines emerged as opportunities for childhood obesity prevention in neighborhoods with high obesity risk.

Obstetric Racial Disparities in the Era of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial and the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: To evaluate the influence of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial and the coronavirus disease 2019 (COVID-19) pandemic on racial and ethnic differences in labor induction, pregnancy-associated hypertension, and cesarean delivery among non-Hispanic Black and non-Hispanic White low-risk, first-time pregnancies. METHODS: We conducted an interrupted time series analysis of U.S. birth certificate data from maternal non-Hispanic Black and non-Hispanic White race and ethnicity, first pregnancy, 39 or more weeks of gestation, with no documented contraindication to vaginal delivery or expectant management beyond 39 weeks. We compared the rate of labor induction (primary outcome), pregnancy-associated hypertension, and cesarean delivery during three time periods: pre-ARRIVE (January 1, 2015-July 31, 2018), post-ARRIVE (November 1, 2018-February 29, 2020), and post-COVID-19 (March 1, 2020-December 31, 2021). RESULTS: In the post-ARRIVE period, the rate of labor induction increased in both non-Hispanic White and non-Hispanic Black patients, with no statistically significant difference in the magnitude of increase between the two groups (rate ratio for race [RR race ] 0.98, 95% CI, 0.95-1.02, P =.289). Post-COVID-19, the rate of labor induction increased in non-Hispanic White but not non-Hispanic Black patients. The magnitude of the rate change between non-Hispanic White and non-Hispanic Black patients was significant (RR race 0.95, 95% CI, 0.92-0.99, P =.009). Non-Hispanic Black pregnant people were more likely to have pregnancy-associated hypertension and more often delivered by cesarean at all time periods. CONCLUSION: Changes in obstetric practice after both the ARRIVE trial and the COVID-19 pandemic were not associated with changes in Black-White racial differences in labor induction, cesarean delivery, and pregnancy-associated hypertension.

Prenatal Vaccination Patterns among Birthing Individuals with History of Preterm Birth in the Pre- and Post-COVID Era.

OBJECTIVE: This study aims to explore vaccination acceptance among individuals with a history of preterm birth between March and June during the pre-COVID (2019), early-COVID (2020), and late-COVID (2021) periods. STUDY DESIGN: This is a cross-sectional, retrospective cohort study of pregnant individuals with a history of preterm birth (<37 weeks' gestation) who initiated care of a subsequent pregnancy during pre-COVID (March-June 2019), early-COVID (March-June 2020), or late-COVID (March-June 2021). The primary outcome of interest was vaccination status for influenza, Tdap, and COVID-19 vaccines. Fisher's exact and chi-square tests were used to investigate association between vaccination status and time periods, race/ethnicity, and insurance. RESULTS: Among 293 pregnancies, influenza vaccination rate was highest in early-COVID (p < 0.05). There was no statistically significant difference in Tdap or COVID-19 vaccination between time periods. COVID-19 vaccination was highest in individuals with private insurance (p < 0.05). There was no statistically significant difference in vaccination status by race/ethnicity. CONCLUSION: In this study on high-risk pregnant individuals, the majority of our cohort remained unvaccinated against COVID-19 into the late-COVID period. Additionally, their influenza vaccination rates were greater than the national average in early-COVID and substantially lower than the national average in late-COVID. This shift in influenza vaccination acceptance may have been sparked by COVID-19 vaccine distribution beginning in January 2021 leading to overall vaccination hesitancy. Standardized guidelines and counseling concerning prenatal safety in recommended immunizations may serve as important tools of reassurance and health promotion. KEY POINTS: · Maternal infections during pregnancy are a risk factor for preterm birth.. · High-risk cohort had low influenza vaccination post-COVID possibly due to COVID-19 vaccine hesitancy.. · Vaccination education may be a uniquely important tool among high-risk pregnant patients..

Feeding, television, and sleep behaviors at one year of age in a diverse sample.

Background: Healthy lifestyle behaviors that can prevent adverse health outcomes, including obesity, are formed in early childhood. This study describes feeding, television, and sleep behaviors among one-year-old infants and examines differences by sociodemographic factors. Methods: Caregivers of one-year-olds presenting for well care at two clinics, control sites for the Greenlight Study, were queried about feeding, television time, and sleep. Adjusted associations between sociodemographic factors and behaviors were performed by modified Poisson (binary), multinomial logistic (multi-category), or linear (continuous) regression models. Results: Of 235 one-year-olds enrolled, 81% had Medicaid, and 45% were Hispanic, 36% non-Hispanic Black, 19% non-Hispanic White. Common behaviors included 20% exclusive bottle use, 32% put to bed with bottle, mean daily juice intake of 4.1 ± 4.6 ounces, and active television time 45 ± 73 min. In adjusted analyses compared to Hispanic caregivers, non-Hispanic Black caregivers were less likely to report exclusive bottle use (odds ratio: 0.11, 95% confidence interval [CI] 0.03-0.39), reported 2.4 ounces more juice (95% CI 1.0-3.9), 124 min more passive television time (95% CI 60-188), and 37 min more active television time (95% CI 10-64). Increased caregiver education and higher income were associated with 0.4 (95% CI 0.13-0.66) and 0.3 (95% CI 0.06-0.55) more servings of fruits and vegetables per day, respectively. Conclusion: In a diverse sample of one-year-olds, caregivers reported few protective behaviors that reduce the risk for adverse health outcomes including obesity. Differences in behavior by race/ethnicity, income, and education can inform future interventions and policies. Future interventions should strive to create culturally effective messaging to address common adverse health behaviors.

Reported changes in romantic and sexual behavior among college and graduate students during COVID-19.

Objective: To understand changes in romantic and sexual behavior among college and graduate students in North Carolina during COVID-19. Participants: Participants were between 18-30 years old and enrolled in a two- or four-year college or graduate program in North Carolina (n = 926). Methods: A cross-sectional web-based survey was administered to college and graduate students to assess romantic and sexual behavioral changes during COVID-19. Results: Participants continued to engage in in-person sexual intercourse during COVID-19 and reported an increase in online and virtual dating. Although the majority of participants reported following COVID-19 guidelines, they did not frequently use risk mitigation strategies such as declining kissing or sex due to COVID-19 concerns, inquiring about recent COVID-19 tests, or having sexual contact without kissing. Conclusion: Study findings suggest a need for colleges and universities to help students manage COVID-19 prevention in intimate relationships.

Colchicine for the Prevention of Recurrent Arrhythmia After Catheter Ablation of Atrial Fibrillation: Results of a Single-Center, Retrospective Study.

BACKGROUND: There is evidence to suggest that colchicine reduces the risk of recurrent atrial fibrillation (AF) after catheter ablation; however, the tolerability and safety of colchicine in routine practice is unknown. METHODS: Patients undergoing catheter ablation for AF who received colchicine after ablation were matched 1:1 to patients who did not by age, sex, and renal function. Recurrent AF was compared between groups categorically at 12 months and via propensity weighted Cox proportional hazards models with and without a 3-month blanking period. RESULTS: Overall, 180 patients (n = 90 colchicine and n = 90 matched controls) were followed for a median (Q1, Q3) of 10.3 (7.0, 12.0) months. Mean age was 65.3 ± 9.1 years, 33.9% were women, mean CHA2DS2-VASc score was 2.9 ± 1.5, and 51.1% had persistent AF. Most patients (70%) received colchicine 0.6 mg daily for a median of 30 days. In the colchicine group, 55 patients (61.1%) were receiving at least one known interacting medication with colchicine. After ablation, one patient required colchicine dose reduction and four patients required discontinuation. After adjusting for covariate imbalance using propensity weighting, no significant association between colchicine use and AF recurrence was identified (adjusted hazard ratio 0.94, 95% confidence interval [CI] 0.48-1.85; p = 0.853). No significant association was found between colchicine use and all-cause hospitalizations (adjusted odds ratio 0.74, 95% CI 0.28-1.96; p = 0.548). CONCLUSION: Despite the frequent presence of drug-drug interactions, a 30-day course of colchicine is well-tolerated after AF ablation; however, we did not observe any association between colchicine and lower rates of AF recurrence or hospitalization.

Implementation of a validated post-operative opioid nomogram into clinical gynecologic surgery practice: A quality improvement initiative.

Objectives: The Gynecologic Oncology Postoperative Opioid use Predictive (GO-POP) calculator is a validated tool to provide evidence-based guidance on post-operative opioid prescribing. The objective of this study was to evaluate the impact of the implementation of GO-POP within an academic Gynecologic Oncology division. Methods: Two cohorts of patients (pre-implementation and post-implementation) who underwent surgery were compared with reference to GO-POP calculator implementation. All patients were included in the post-implementation group, regardless of GO-POP calculator use. An additional expanded-implementation cohort was used to compare pain control between GO-POP users and non-GO-POP users prospectively. Wilcoxon rank sum tests or ANOVA for continuous variables and Chi-square or Fisher's exact tests were used to categorical variables. Results: The median number of pills prescribed post-operatively decreased from 15 pills (Q1: 10, Q3: 20) to 10 pills (Q1: 8, Q3: 14.8) after implementation (p < 0.001). In the expanded-implementation cohort (293 patients), 41% patients were prescribed opioids using the GO-POP calculator. An overall median of 10 pills were prescribed with no difference by GO-POP calculator use (p = 0.26). Within the expanded-implementation cohort, refill requests (5% vs 9.2%; p = 0.26), clinician visits (0.8% vs 0.6%, p = 1), ED or urgent care visits (0% vs 2.3%, p = 0.15) and readmissions (0% vs 1.7%, p = 0.27) for pain did not differ between those prescribed opioids with and without the GO-POP calculator. Conclusions: A 33% reduction in post-operative opioid pills prescribed was seen following implementation of the GO-POP calculator into the Gynecologic Oncology division without increasing post-operative pain metrics or encounters for refill requests.

Underrepresentation of African Americans in Plastic Surgery: Examining Demographics, Specialty Factors, and Medical School Experiences.

BACKGROUND: Racial representation among medical trainees translates into physicians that are able to communicate with diverse patient populations and are perceptive to health disparities. This is important within plastic surgery where an optimal physicianpatient relationship is essential to health outcomes. OBJECTIVE: The purpose of this study is to address underrepresentation of African Americans (AA) in plastic surgery through improving understanding of factors that may contribute to AA medical student interest in plastic surgery. DESIGN: This was a voluntary, cross-sectional survey. An online survey was designed to collect information on demographics, specialty factor importance, medical school experiences, and plastic surgery interest among medical students. The survey was distributed to medical students within three national medical organizations between August 2018 and February 2019. The following groups of respondents were statistically COMPARED: AAs interested vs. AAs not interested in plastic surgery and AA vs. Caucasian medical students both interested in plastic surgery. SETTING: Online survey for medical students in the United States. PARTICIPANTS: All 428 participants were medical students that belonged to at least 1 of the 3 national medical organizations between August 2018 and February 2019. RESULTS: The survey was completed by 428 participants of which 142 were excluded for incomplete surveys, leaving 286 (66.8%) participants to be included in the study. Among AA medical students, 128 (75.3%) were not interested in Plastic Surgery and 42 (24.7%) were interested. The 2 groups were similar demographically but differed significantly across multiple specialty factors and medical school experiences (p < 0.05). When compared to interested Caucasian medical students (n = 30), interested AA medical students differed significantly in demographics, specialty factors, and medical school experiences (p < 0.05). CONCLUSIONS: This study supports the implementation of medical school interventions emphasizing specialty factors and medical school experiences unique to AA medical students interested in plastic surgery to promote their application into the specialty.

Outcomes and Complications for Concurrent Hernia Repair Among Women Undergoing Hysterectomy.

OBJECTIVE: To assess whether concurrent hernia repair at time of hysterectomy is associated with increased complications. METHODS: In this retrospective cohort study, patients who underwent hysterectomy and hysterectomy with concurrent hernia repair were queried using the American College of Surgeons' National Surgical Quality Improvement Program participant use file (2005-2019). Propensity score matching was performed 1:1 with respect to preoperative and operative characteristics. Outcomes were operation time, length of stay (LOS), and major and minor complications. A secondary analysis of patients who underwent hysterectomy for malignancy was performed. RESULTS: A total of 369,010 patients underwent hysterectomy, and 5,071 of those underwent hysterectomy with concurrent hernia repair. After propensity score matching, there were 5,071 patients in each arm. Hysterectomy with concurrent hernia repair had a longer operation time by 46 minutes (95% CI 42.6-49.6; P <.001) and longer LOS after surgery by 0.71 days (95% CI 0.59-0.84; P <.001). Hysterectomy with concurrent hernia repair was associated with a 21.9% higher risk (15.6% vs 12.8%; 95% CI 1.11-1.34, P <.001) of major complications and was associated with a 34.5% higher risk (7.4% vs 5.5%; 95% CI 1.16-1.56, P <.001) of minor complications. In subgroup analyses, there was no significant increase in risk among patients with body mass indexes (BMIs) lower than 40, those who were younger than age 40 years or older than age 60 years, and those with tobacco use, diabetes, or a minimally invasive surgical approach. For patients undergoing hysterectomy for malignancy, hysterectomy with concurrent hernia repair was associated with a 32-minute longer operation time (95% CI 25.2-38.8; P <.001) and a 0.35-day longer LOS (95% CI 0.04-0.67, P =.027), but there was no significant difference in major and minor complications. CONCLUSION: Hysterectomy with concurrent hernia repair is associated with increased operation time, LOS, and risk of major and minor complications compared with hysterectomy without hernia repair. The subgroup analyses suggest that hysterectomy with concurrent hernia has a similar complication risk as hysterectomy without hernia repair in select populations, such as those with BMIs lower than 40 or with known malignancy.

Does treatment at a level I trauma center reduce disparities in patient outcomes for open tibia fractures? A retrospective analysis of the National trauma Databank.

Background: Race and insurance status are independent predictors of healthcare outcomes following lower-extremity trauma. Level 1 trauma centers show better outcomes overall, but it is has not been extensively studied as to whether they specifically lower complication rates and shorten length of stay in those with Black race, with low socioeconomic status, and/or a lack of private health insurance. We performed a study with the objective of determining whether Level I trauma centers can improve the complication rate of those shown to be at high risk of experiencing adverse outcomes due to socioeconomic differences. Hypothesis: Level 1 trauma centers will be successful in mitigating the disparity in complication rates and length of stay associated with racial and socioeconomic differences among trauma patients experiencing an open tibia fracture. Patients and methods: The National Trauma Databank was reviewed from 2008 to 2015, identifying 81,855 encounters with an open tibia fracture, and 33,047 at a Level I trauma center. Regression models determined effects of race and insurance status on outcomes by trauma center while controlling for confounders. Results: Black race [OR 1.36, 95% CI, 1.17-1.58; p < 0.05] and "other" race [OR 1.28, 95% CI, 1.07-1.52; p < 0.05] were associated with higher odds of injury-specific complications. Patients without private insurance and of non-White or Black race in comparison to White patients had a significantly longer length of stay [coefficient 1.66, 95% CI, 1.37-1.94; p < 0.001]. These differences persisted in patients treated at an American College of Surgeons (ACS) Level I trauma center. Discussion: Treatment at an ACS Level I trauma center did not reduce the independent effects of race and insurance status on outcomes after open tibia fracture, emphasizing the need to recognize this disparity and improve care for at-risk populations.

Factors Associated with Guideline Concordant Clinician Counseling about Low-Dose Aspirin to Prevent Preeclampsia in Nulliparous Patients.

OBJECTIVE: The primary aim of this study was to examine the United States Preventative Services Task Force (USPSTF) guidelines concordant low-dose aspirin (LDA) counseling and factors associated with counseling in nulliparous birthing individuals. STUDY DESIGN: We conducted a retrospective cohort study of nulliparous birthing individuals who delivered between January 1, 2019 and June 30, 2020 and received prenatal care at the Duke High Risk Obstetrical Clinics (HROB). All nulliparous patients over 18 years old who established or transferred care to HROB by 16 weeks, 6 days were included in the analysis. We excluded patients with more than two previous first-trimester pregnancy losses, multiple gestation, a known contraindication to LDA, initiation of LDA prior to their prenatal care, or documented medical history of coagulation disorder. Bivariate associations between demographic/medical characteristics and our primary outcome, receipt of counseling (yes/no), were assessed using two-sample t-tests for continuous variables and chi-square or Fisher's exact test for categorical variables. Factors significantly associated with the primary outcome (p < 0.05) were entered into the multivariable logistic regression model. RESULTS: Among 391 birthing individuals included in the final analysis cohort, 51.7% of eligible patients received guideline consistent LDA counseling. Factors associated with increased odds of LDA counseling were advanced maternal age (adjusted odds ratio [aOR]: 1.05, 95% confidence interval [CI]: 1.01-1.09), Black race compared with White race (aOR:1.75, 95% CI: 1.03-2.98), chronic hypertension (aOR: 4.17, 95% CI: 1.82-9.55), and obesity (aOR: 5.02, 95% CI: 3.12-8.08). CONCLUSION: Approximately half of all nulliparous birthing individuals had appropriately documented LDA counseling. The USPSTF guidelines on LDA for preeclampsia risk reduction are complex, which may lead to ineffective provider adherence. Efforts to simplify guidelines and improve LDA counseling are vital to ensuring this low-cost, evidence-based preeclampsia prevention is used in a consistent and equitable manner. KEY POINTS: · A total of 51.7% of eligible patients received guideline consistent LDA counseling.. · Advanced maternal age , body mass index > 30, Black race, and chronic hypertension associated with increased odds of counseling.. · Among patients most likely to be counseled, high numbers did not receive LDA counseling..

Standard Restrictions vs Expedited Activity After Pelvic Organ Prolapse Surgery: A Randomized Clinical Trial.

Importance: Restrictions on postoperative activity following pelvic organ prolapse (POP) surgery are not evidence based. Nonetheless, many pelvic surgeons place lifting and activity restrictions on patients following surgery. Objective: To evaluate whether expedited activity results in noninferior anatomic and symptomatic outcomes compared with standard activity restrictions after POP surgery. Design, Setting, and Participants: This randomized noninferiority clinical trial included patients undergoing vaginal or laparoscopic apical reconstructive surgery for POP between July 1, 2020, and October 31, 2021, at a single academic tertiary referral center in Durham, North Carolina. Anatomic outcomes were assessed by masked examiners, and subjective outcomes were assessed via validated surveys, both completed at 3 months postoperatively. Patients meeting minimum physical activity criteria with at least stage II bothersome POP were eligible. A total of 218 patients were approached, of whom 123 were randomly assigned and 107 had complete outcome data and were included in the analysis. Interventions: Patients were randomly assigned to receive standard restrictions vs expedited postoperative activity instructions. Main Outcomes and Measures: The anatomic coprimary outcome was maximum anatomic POP support loss (SLmax), which is the most distal point of pelvic organ support loss according to the Pelvic Organ Prolapse Quantification System (noninferiority margin, 1.0 cm). The symptomatic coprimary outcome was the Pelvic Organ Prolapse Distress Inventory (POPDI) symptom score (noninferiority margin, 34.3 points). Differences between outcomes were assessed using linear regression models controlling for baseline SLmax and POPDI, respectively. Results: Of 123 participants randomized, 107 had complete 3-month outcome data and were included in the analysis. Mean (SD) age was 62.8 (10.1) years. At 3 months, mean (SD) SLmax was -1.7 (1.4) cm in the expedited group and -1.5 (1.4) cm in the standard group (P = .44). After adjusting for baseline SLmax, the mean maximum support loss was 0.18 cm higher within the vaginal canal in the expedited group (95% CI, -0.68 to 0.33 cm). The coprimary outcome of POPDI score was a mean (SD) 23.7 (41.8) points in the expedited group vs 25.7 (39.3) points in the standard group (P = .80). After adjusting for baseline scores, mean POPDI scores were 5.79 points lower in the expedited group (95% CI, -20.41 to 8.84). Conclusions and Relevance: The findings demonstrate that expedited activity after prolapse surgery results in noninferior anatomic and symptomatic prolapse outcomes. It is reasonable to instruct patients undergoing minimally invasive prolapse surgery to resume physical activities ad lib postoperatively. Trial Registration: ClinicalTrials.gov Identifier: NCT04329715.

Factors Associated With Triage Decisions in Older Adult Trauma Patients: Impact on Mortality and Morbidity.

INTRODUCTION: As medical advances have significantly increased the life expectancy among older adults, the number of older patients requiring trauma care has risen proportionately. Nevertheless, it is unclear among this growing population which sociodemographic and economic factors are associated with decisions to triage and transfer to level I/II centers. This study aims to assess for any association between patient sociodemographic characteristics, triage decisions, and outcomes during acute trauma care presentations. METHODS: The National Trauma Data Bank was queried for patients aged 65 and older with an injury severity score > 15 between the years 2007 to 2017. Factors associated with subsequent levels of triage on presentation were assessed using multivariate logistic regression, and associations of levels of triage with outcomes of mortality, morbidity, and hospital length of stay are examined using logistic and linear regression models. RESULTS: Triage of 210,310 older adult trauma patients showed significant findings. American Indian patients had higher odds of being transferred to level I/II centers, while Asian, Black, and Native Hawaiian patients had lower odds of being transferred to level I/II centers when compared to Caucasian patients (P < 0.001). Regarding insurance, self-pay (uninsured) patients were less likely to be transferred to a higher level of care; however, this was also demonstrated in private insurance holders (P < 0.001). Caucasian patients had significantly higher odds of mortality, with Black patients (odds ratio [OR] 0.80 [0.75, 0.85]) and American Indian patients (OR 0.87 [0.72, 1.04]) having significantly lower odds (P < 0.001). Compared to government insurance, private insurance holders (OR 0.82 [0.80, 0.85]) also had significantly lower odds of mortality, while higher odds among self-pay were observed (OR 1.75 [1.62, 1.90]), (P < 0.001). CONCLUSIONS: Access to insurance is associated with triage decisions involving older adults sustaining trauma, with lower access increasing mortality risk. Factors such as race and gender were less likely to be associated with triage decisions. However, due to this study's retrospective design, further prospective analysis is necessary to fully assess the decisions that influence trauma triage decisions in this patient population.