Cancer incidence, type, and survival after bariatric surgery.

BACKGROUND: Many types of cancer have been found to be associated with being overweight or obese. Literature has demonstrated a reduction in cancer risk in patients who have undergone bariatric surgery. OBJECTIVES: To compare the incidence and types of new cancer diagnoses, cumulative cancer incidence, cancer risk, and overall survival in patients with obesity who underwent bariatric surgery with that of those who did not. SETTING: Community-based academic medical center. METHODS: We retrospectively compared the rates and types of new incident cancers in a bariatric surgery cohort (Bariatric group) with those of a non-surgical cohort (Comparison group). The Comparison group was chosen from patients who had a clinic visit in our health system within 30 days of each bariatric surgical operation and matched on age, sex, and body mass index. Patients who had a cancer diagnosis prior to having bariatric surgery were excluded from the Bariatric group and patients who had a cancer diagnosis prior to the clinic visit on which they were matched were excluded from the Comparison group. Relative risk of cancer by type was calculated. Chi-square and Fisher exact tests were used for categorical data analysis, and Wilcoxon rank-sum for continuous data. The Kaplan Meier estimator with the log-rank test was used to compare overall survival between groups, while competing risks survival analysis with the Gray test for equality was used to compare cancer incidence in the Surgery group with that in the Comparison group. RESULTS: After matching, the Bariatric group had 1593 patients and the Comparison group had 2156. The Bariatric and Comparison groups had 82 and 222 new incident cancer cases, respectively (P < .001). The 10-year incidence of any new cancer in the Bariatric group was 6.5%, compared with an incidence of 12.1% in the Comparison group (P < .001). Relative risk of cancer in the Bariatric group was lower than that of the Comparison group, with the greatest differences in endometrial (88.8%), kidney (77.4%), thyroid (72.9%), and ductal carcinoma in situ (71.2%) cancers. The 10-year overall survival rate was higher in the Bariatric group than in the Comparison group, 93.3% versus 80.6%, respectively (P < .001). CONCLUSIONS: Bariatric surgery reduces the risk for developing cancer and offers survival advantage when compared with similar patients who do not undergo bariatric surgery.

The Incidence of Complications Following Scarf Osteotomy for the Treatment of Hallux Valgus: A Systematic Review With Meta-Analysis.

The Scarf osteotomy is a surgical procedure performed to correct a hallux valgus deformity. Multiple studies have supported use of the procedure with favorable outcomes. In contrast, there have been studies showing a significant complication rate with the procedure. Incidence of complications remains underreported in the literature. We performed a systemic review and meta-analysis examining a wide range of reported complications and associated clinical outcomes from the Scarf osteotomy. One hundred and sixteen publications were identified and 25 (21.6%) met our inclusion criteria. A total of 1583 Scarf procedures were included. Weighted mean follow-up was 26.4 months [range 12-168 months]. We found a 5.1% rate of recurrence, 3.5% rate of troughing, 1.0% rate of avascular necrosis, 1.8% rate of nonunion, 2.7% rate of malunion, 2.4% rate of infection, 5.3% rate of complex regional pain syndrome, and 3.4% rate of hallux varus. An average decrease in intermetatarsal angle of 6.3° was observed. No statistical difference was found in outcomes when comparing Scarf versus Scarf with additional procedure performed at time of surgery. To our knowledge, this systematic review and meta-analysis contains the highest number of Scarf procedures analyzed and presents complication rates on multiple adverse outcomes.

Temporal Artery Biopsy: When Is It Worth the Headache?

BACKGROUND: Temporal artery biopsy is ordered when clinical symptoms and an elevated C-reactive protein values and/or erythrocyte sedimentation rates suggest giant cell arteritis. The percentage of temporal artery biopsies positive for giant cell arteritis is low. The objectives of our study were to analyze the diagnostic yield of temporal artery biopsies at an independent academic medical center and to develop a risk stratification model for triaging patients for possible temporal artery biopsy. METHODS: We retrospectively reviewed the electronic health records of all patients who underwent temporal artery biopsy in our institution from January 2010 through February 2020. We compared clinical symptoms and inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) values of patients whose specimens were positive for giant cell arteritis with those of patients with negative specimens. Statistical analysis included descriptive statistics, chi-square test, and multivariable logistic regression. A risk stratification tool, which included point assignments and measures of performance, was developed. RESULTS: Of 497 temporal artery biopsies for giant cell arteritis performed, 66 were positive and 431 were negative. Jaw/tongue claudication, elevated inflammatory marker values, and age were associated with a positive result. Using our risk stratification tool, 3.4% of low-risk patients, 14.5% of medium-risk patients, and 43.9% of high-risk patients were positive for giant cell arteritis. CONCLUSIONS: Jaw/tongue claudication, age, and elevated inflammatory markers were associated with positive biopsy results. Our diagnostic yield was much lower when compared with a benchmark yield determined in a published systematic review. A risk stratification tool was developed based on age and the presence of independent risk factors.

Postoperative Outcomes in the Plain Community Population of Western Wisconsin.

BACKGROUND: Residents of plain communities constitute an underserved minority population that is not reliably captured in contemporary surgical outcomes research. We hypothesized that plain communities (PC) patients would have higher postoperative complication rates than a general surgical population. METHODS: A retrospective review of 30-day postoperative outcomes for PC patients compared to a majority (non-PC) matched patient population from September 2014 to March 2020 was performed. The primary outcome measure was any complication within 30 days of surgery. RESULTS: 270 PC patients were matched with 493 non-PC patients. The 30-day complication rate was higher for the PC group (6.3% vs 3.7%, P = .09), though not statistically significant. There was significantly lower utilization of preventive care services, and postoperative follow-up among PC patients. DISCUSSION: Although our regional PC surgical patient population utilized preventive and postoperative health care services less than the non-PC population, there was no statistically significant difference in overall 30-day postoperative morbidity or mortality.

Optimized infection control practices augment the robust protective effect of vaccination for ESRD patients during a hemodialysis facility SARS-CoV-2 outbreak.

BACKGROUND: While dialysis patients are at greater risk of serious SARS-CoV-2 complications, stringent infection prevention measures can help mitigate infection and transmission risks within dialysis facilities. We describe an outbreak of 14 cases diagnosed in a hospital-based outpatient ESRD facility over 13 days in the second quarter of 2021, and our coordinated use of epidemiology, viral genome sequencing, and infection control practices to quickly end the transmission cycle. METHODS: Symptomatic patients and staff members were diagnosed by RT-PCR. Facility-wide screening utilized SARS-CoV-2 antigen tests. SARS-CoV-2 genome sequences were obtained from residual diagnostic specimens. RESULTS: Of the 106 patients receiving dialysis in the facility, 10 were diagnosed with SARS-CoV-2 infection, as was 1 patient support person. Of 3 positive staff members, 2 were unvaccinated and had provided care for 6 and 4 of the affected patients, respectively. Sequencing demonstrated that all cases in the cluster shared an identical B.1.1.7./Alpha substrain. Attack rates were greatest among unvaccinated patients and staff. Vaccine effectiveness was 88% among patients. CONCLUSIONS: Prompt recognition of an infection cluster and rapid intervention efforts successfully ended the outbreak. Alongside consistent adherence to core infection prevention measures, vaccination was highly effective in reducing disease incidence and morbidity in this vulnerable population.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

BACKGROUND: Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS: Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS: 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION: Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

Outbreak or pseudo-outbreak? Integrating SARS-CoV-2 sequencing to validate infection control practices in a dialysis facility.

BACKGROUND: The COVID-19 pandemic poses a particularly high risk for End Stage Renal Disease (ESRD) patients so rapid identification of case clusters in ESRD facilities is essential. Nevertheless, with high community prevalence, a series of ESRD patients may test positive contemporaneously for reasons unrelated to their shared ESRD facility. Here we describe a series of 5 cases detected within 11 days in November 2020 in a hospital-based 32-station ESRD facility in Southwest Wisconsin, the subsequent facility-wide testing, and the use of genetic sequence analysis to evaluate links between cases. METHODS: Four patient cases and one staff case were identified in symptomatic individuals by RT-PCR. Facility-wide screening was conducted using rapid SARS-CoV-2 antigen tests. SARS-CoV-2 genome sequences were obtained from residual diagnostic specimens. RESULTS: Facility-wide screening of 47 staff and 107 patients identified no additional cases. Residual specimens from 4 of 5 cases were available for genetic sequencing. Clear genetic differences proved that these contemporaneous cases were not linked. CONCLUSIONS: With high community prevalence, epidemiological data alone is insufficient to deem a case cluster an outbreak. Cluster evaluation with genomic data, when available with a short turn-around time, can play an important role in infection prevention and control response programs.

Increased Incidence of Giant Cell Arteritis After Introduction of a Live Varicella Zoster Virus Vaccine.

BACKGROUND: Varicella zoster virus (VZV) has been associated with giant cell arteritis (GCA). The introduction of a live attenuated vaccine against this virus (ZVL) might have changed the incidence of GCA. METHODS: The incidence of GCA was retrospectively measured using 2 matched cohorts seen in a regional health system located in the Midwestern United States: ZVL recipients from the years 2007 through 2015 following the introduction of the vaccine and nonrecipients from the years 2000 through 2015. RESULTS: In the ZVL cohort, a significant increase of GCA was associated with clinical criteria alone for the diagnosis of GCA (hazard ratio [HR], 2.70; 95% CI, 1.48-4.45; P = .004). In addition, using only pathologically confirmed GCA, the same matched cohort comparison analysis also found that ZVL recipients were at significantly higher risk than those who did not receive ZVL (HR, 2.70; 95% CI, 1.48-4.95; P = .001). CONCLUSION: Using a matched cohort, retrospective comparison, ZVL was associated with an increased incidence of GCA.

Validation of the Yale Food Addiction Scale 2.0 in Patients Seeking Bariatric Surgery.

BACKGROUND: The Yale Food Addiction Scale (YFAS) was developed in 2009 to assess food addiction (FA); a revised version was released in 2016 (YFAS 2.0). The objective of this study was to determine the statistical and clinical validity of the YFAS 2.0 in adults seeking bariatric surgery. METHODS: Patients who underwent a preoperative psychological evaluation in preparation for bariatric surgery from 2015 to 2018 were included. The YFAS 2.0 was administered as part of routine clinical care and validated against an assessment battery of standardized clinical measures. Statistical analyses included chi-square and Wilcoxon rank sum tests and calculation of Spearman's rank correlation coefficients. RESULTS: Overall, 1061 patients were included. Mean age and BMI were 47.5 ± 12.9 years and 46.9 ± 13.4 kg/m2, respectively. There were 196 (18%) patients who screened positive on the YFAS 2.0 (21% mild, 23% moderate, and 56% severe FA). The YFAS 2.0 demonstrated strong convergent validity where patients who met criteria for FA had significantly increased levels of binge eating (p < 0.001), emotional eating (p < 0.001), and lower self-efficacy (p < 0.001). Discriminant validity was demonstrated by lack of association with alcohol use (p = 0.319). The YFAS 2.0 was significantly correlated with total scores for depression (p < 0.001), anxiety (p < 0.001), bipolar disorder symptoms (p < 0.001), and trauma history (p < 0.001). CONCLUSIONS: The prevalence of FA in a large sample of patients seeking bariatric surgery was consistent with previous literature. These data suggest that the YFAS 2.0 is psychometrically valid, demonstrating strong construct validity, and is a clinically useful measure of FA severity in patients pursuing bariatric surgery.

Career Satisfaction, Gender Bias, and Work-Life Balance: A Contemporary Assessment of General Surgeons.

OBJECTIVE: To identify factors and patterns of career and life satisfaction among general surgery residency graduates who completed all of their general surgery training after the implementation of duty hour restrictions. DESIGN: A 91-point electronic survey was distributed to assess experiences during medical school, residency, current surgical practice and work-life balance. Descriptive statistics and chi-square tests were completed. SETTING: Twenty-nine ACGME-accredited surgery residencies. PARTICIPANTS: Graduates of surgery residencies between 2008 and 2018. RESULTS: Three hundred thirty-six surgeons completed the survey (21% response rate); 42% (n = 141) were female. Seventy-nine percent (n = 81) of female and 92% (n = 138) of male surgeons reported overall career satisfaction (p = 0.004). Overall, 97% and 94% reported feeling competent to practice clinically and operate independently at the conclusion of their training. Thirty-four percent (n = 48) of women experienced gender bias/discrimination while on their medical school surgery rotation, compared to 6% (n = 12) of men (p < 0.001). Sixty-two percent (n = 63) of female surgeons reported gender bias in their practice, compared to 4% (n = 6) of men (p < 0.001). Of respondents with children, female surgeons were more likely to think having a child negatively affected their career advancement (p = 0.004), and 24% of female surgeons and 11% of male surgeons do not think having a family is supported by their practice (p = 0.02). If given the opportunity to choose a career again, 21% of female surgeons and 13% of male surgeons would choose a different profession (p = 0.13). CONCLUSIONS: General surgeons who completed their training after implementation of duty hour regulations are confident in their preparation for clinical practice. Female surgeons were less likely to be satisfied with their career and they report significantly more bias during their professional development and career. Work-life balance challenges were similar among men and women. Efforts are necessary to reduce gender bias across the spectrum of general surgeon training/career and to promote well-being among surgeons in practice.

Lack of Correlation Between Subjective and Objective Measures of Gastroesophageal Reflux Disease: Call for a Novel Validated Assessment Tool.

Background. Objective measures including the DeMeester score, lower esophageal sphincter (LES) pressure, acid exposure time, and body mass index (BMI) are used to determine gastroesophageal reflux disease (GERD) severity and eligibility for various antireflux surgical procedures. The GERD Health-Related Quality of Life (GERD-HRQL) survey is widely used to evaluate patients' subjective severity of symptoms and GERD-related quality of life. The purpose of this project was to identify whether or not the subjective measure (GERD-HRQL) correlated with objective measures (DeMeester score, LES, acid exposure time, and BMI) of GERD severity. Methods. A retrospective review of the medical records of patients who underwent antireflux surgery from 2013-2018 was completed. Patients' GERD severity was measured preoperatively and postoperatively using the GERD-HRQL. Statistical analysis included the calculation of Spearman correlation coefficients, Wilcoxon rank sum, sign, and chi-square tests. Results. 151 patients were included in the study; 64% were female. The mean age and BMI were 54.6 ± 14.6 years and 30.1 ± 4.1 kg/m2, respectively. The mean preoperative DeMeester score was 43.1 ± 36.1, LES pressure was 19.9 ± 18.4 mmHg, and acid exposure time was 11.4 ± 9.6. Mean GERD-HRQL scores decreased from 27.3 ± 9.2 preoperative to 5.3 ± 4.5 postoperative; P < .0001. Preoperative GERD-HRQL scores were not correlated with the DeMeester score (r = .11; P = .389), LES pressure (r = -.20; P = .089), acid exposure time (r = .05; P = .755), BMI (r = .10; P = .329), or age (r = -.16; P = .118). Conclusions. Total GERD-HRQL scores significantly decreased from pre- to postoperative. There was no correlation between subjective and objective GERD scoring. These data indicate the need for both physiologic evaluation and subjective assessment of patient symptoms during preoperative workup. There is a need for a contemporary, validated GERD questionnaire that correlates with objective pH testing.

Infant Vaccinations among Mothers with Substance-Use Disorders: A Comparative Study.

Introduction: Infants of mothers with substance use disorder (SUD) are exposed to complex social environments and increased childhood health risks that can lead to adverse consequences throughout the lifespan. GunderKids, a voluntary, specialized, comprehensive pediatric care management program, was developed to mitigate many of these adverse consequences. Our organization is evaluating several clinical outcomes related to health and development in children born to women with SUD. The current study addressed the timeliness of vaccination coverage among these infants.Methods: This descriptive comparative preliminary study evaluated data of infants and their mothers with SUD who were previously identified during prenatal care visits either by self-report or by positive urine screens. Sociodemographic and vaccination data were extracted from a longitudinal master dataset of variables developed and maintained through retrospective review of electronic health records (EHRs) of these mothers and their infants. Timeliness of vaccination coverage of SUD-exposed infants participating in GunderKids was compared with that of SUD-exposed infants receiving standard pediatric care and was determined using a cumulative vaccinations method.Results: Overall, infants in the GunderKids group (n=50) had more timely vaccination coverage than those receiving standard pediatric care (n=20). Examples of timelier coverage included Haemophilus influenzae type b (Hib) at 4 months (P = .01; OR 4.3, 95% CI 1.4-13.4), for pneumococcal (P = .004; OR 6.6, 95% CI 1.8-23.8) and Hib (P = .004; OR 5.8, 95% CI 1.6-21.9) vaccinations at 15 months. More than 77% of GunderKids received all 6-month vaccinations in a timely manner compared with less than 45% of the standard care group; odds ratios suggest that GunderKids had 4.0-5.6 higher odds of receiving 6-month vaccinations.Conclusion: Vaccination coverage of infants participating in GunderKids was timelier than that of infants receiving standard pediatric care. Results suggest that specialized programs like GunderKids may assist in mitigating adverse health consequences and timeliness of vaccination coverage might be used as a proxy for measuring program effectiveness. Further investigation is recommended to determine clinical, individual, and organizational factors that influence parental behaviors and pediatric outcomes within SUD-exposed families.

External Validation of AJCC Eighth Edition of Non-small-cell Lung Cancer Staging Among African Americans.

INTRODUCTION: The American Joint Committee on Cancer (AJCC) eighth staging classification system for non-small-cell lung cancer was based on data from a multinational study consisting of 94,708 patients. African Americans were not included in this large database. MATERIALS AND METHODS: The authors aimed to compare the performance of the AJCC eighth staging system with that of the seventh in predicting overall survival among African Americans utilizing the National Cancer Database. Cases with T- and M- categories were classified into 2 groups based on the AJCC seventh and eighth edition staging systems. Kaplan-Meier curves for overall survival were then constructed for each subgroup. Concordance index was computed using Uno's methodology to assess the overall performance between the 2 staging systems in predicting the mortality. Time-dependent area under the curve was calculated at each follow-up event for the seventh and eighth edition clinical and pathologic staging using an inverse probability of censoring weighted methodology. A 2-sided P-value < .05 was considered to show statistical significance. RESULTS: The database identified a total of 70,606 African American patients in the study period of 2004 through 2014. Area under the curve values were consistently higher for the eighth edition scheme compared with the seventh edition (concordance 0.630 vs. 0.624, respectively; P < .0001 for clinical staging scheme and 0.596 vs. 0.591, respectively; P = .01 for pathologic staging scheme). CONCLUSION: The AJCC eighth edition staging system showed better prognostic value in predicting overall survival when compared with the AJCC seventh edition staging scheme among African American patients with non-small-cell lung cancer.

The role of palliative care in acute trauma: When is it appropriate?

INTRODUCTION: We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS: An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS: 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS: In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.

Is Chief Resident Autonomy Safe for Patients? An Analysis of Quality in Training Initiative (QITI) Data to Assess Chief Resident Performance.

OBJECTIVE: A chief resident service (CRS) provides a unique environment to assess competence throughout all aspects of patient care. The American College of Surgeons National Surgical Quality Improvement Program and Quality in Training Initiative databases are utilized to assess patient outcomes by individual residents with institutional and national comparisons. We hypothesized that residents on the CRS would have equivalent patient care outcomes to peers not on CRS and to chief residents nationally. DESIGN: An institutional National Surgical Quality Improvement Program database was queried from 2014 to 2019 for operations performed on the CRS. Thirty-day complications were compared between CRS and non-CRS postgraduate year (PGY)-5 residents. Quality in Training Initiative reports were used to compare residents on CRS to national PGY-5 residents. Statistical analysis included chi-square tests, and multivariate logistic regression. SETTING: Independent academic medical center. PARTICIPANTS: Chief general surgery residents. RESULTS: A total of 1031 cases were included in the analysis; 562 while off CRS and 469 while on CRS. Thirty-day outcomes were similar for CRS vs non-CRS cases for any complication (8% vs 12%, p = 0.05), unplanned readmissions (6% vs 5%, p = 0.58), and mortality (2% vs 2%, p = 0.99). Adjusting for patient and operative risk factors and procedure type, the rate of any complication after an operation on CRS vs off CRS was similar (odds ratio = 1.46, 95%confidence interval 0.82-2.60; p = 0.20). CRS residents had higher rates of postoperative renal failure (1.3% vs 0.5%, p = 0.008), but lower rates of organ space surgical site infection (0.6% vs 2.9%, p < 0.001), myocardial infarction (0 vs 0.6%, p = 0.04), pneumonia (0.3% vs 1.6%, p = 0.006), septic shock (0.1% vs 1.0%, p = 0.02), transfusion (2.7% vs 8.3%, p < 0.001), and fewer unplanned readmissions (6.1% vs 8.4%, p = 0.029) when compared to PGY-5 residents nationally. CONCLUSIONS: Patient care outcomes provided by PGY-5 residents on a CRS are comparable to those on non-CRS rotations and to PGY-5 residents nationally.

Underrepresented Minorities in General Surgery Residency: Analysis of Interviewed Applicants, Residents, and Core Teaching Faculty.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires diversity in residency. The self-identified race/ethnicities of general surgery applicants, residents, and core teaching faculty were assessed to evaluate underrepresented minority (URM) representation in surgery residency programs and to determine the impact of URM faculty and residents on URM applicants' selection for interview or match. STUDY DESIGN: Data from the 2018 application cycle were collated for 10 general surgery programs. Applicants without a self-identified race/ethnicity were excluded. URMs were defined as those identifying as black/African American, Hispanic/Latino/of Spanish origin, and American Indian/Alaskan Native/Native Hawaiian/Pacific Islander-Samoan. Statistical analyses included chi-square tests and a multivariate model. RESULTS: Ten surgery residency programs received 9,143 applications from 3,067 unique applicants. Applications from white, Asian, Hispanic/Latino, black/African American, and American Indian applicants constituted 66%, 19%, 8%, 7% and 1%, respectively, of those applications selected to interview and 66%, 13%, 11%, 8%, and 2%, respectively, of applications resulting in a match. Among programs' 272 core faculty and 318 current residents, 10% and 21%, respectively, were identified as URMs. As faculty diversity increased, there was no difference in selection to interview for URM (odds ratio [OR] 0.83; 95% CI 0.54 to 1.28, per 10% increase in faculty diversity) or non-URM applicants (OR 0.68; 95% CI 0.57 to 0.81). Similarly, greater URM representation among current residents did not affect the likelihood of being selected for an interview for URM (OR 1.20; 95%CI 0.90 to 1.61) vs non-URM applicants (OR 1.28; 95% CI 1.13 to 1.45). Current resident and faculty URM representation was correlated (r = 0.8; p = 0.005). CONCLUSIONS: Programs with a greater proportion of URM core faculty or residents did not select a greater proportion of URM applicants for interview. However, core faculty and resident racial diversity were correlated. Recruitment of racially/ethnically diverse trainees and faculty will require ongoing analysis to develop effective recruitment strategies.

Impact of Advance Directives on Outcomes and Charges in Elderly Trauma Patients.

Background: As the number of geriatric trauma patients rises, end-of-life planning is of increased importance. A community-wide initiative to increase advance care planning was undertaken in the 1990s, resulting in a high rate (85%) of completed advance directives (ADs). Objectives: To assess the impact of ADs on quality measures of care and outcomes for elderly trauma patients. To determine if the historically high rate of completed ADs in the community applied to the trauma patient population. Design: A single trauma center's registry was retrospectively reviewed. Patients with versus without an AD were compared. A case-control analysis was completed. Statistical analysis included chi-square test, Wilcoxon rank sum, and multivariate linear regression modeling. Setting: American College of Surgeons-verified level II trauma center with a 325-bed teaching hospital. Subjects: Patients ≥55 years admitted as level I or II activations from January 2007 through April 2017. Measurements: Hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and 30-day mortality. Results: Nine hundred thirty-six patients were identified; 173 (18%) had an AD and 763 (82%) did not. ADs were more common among older, female patients. The majority of patients with ADs lived within the medical center's service area (99% vs. 1%) and had a primary care provider within the health care system (72% vs. 28%). Although 30-day mortality was higher in patients with ADs versus without (21% vs. 15%; p = 0.03), this difference was not significant on case-control analysis (20% vs. 15%, p = 0.31). No difference was identified in LOS, ICU days, ventilator days, or charges. Conclusions: Presence of an AD was not associated with any difference in 30-day mortality, LOS, or hospital charges. More widespread efforts at AD education and documentation are necessary, particularly in the setting of trauma.

Continuation in Treatment and Maintenance of Custody of Newborns After Delivery in Women With Opioid Use Disorder.

OBJECTIVE: To identify variables associated with continuation in treatment and maintenance of custody after pregnancies in women with opioid use disorder (OUD). METHODS: The medical records of pregnant women with documented OUD from 2011 to 2018 and with at least 6 months follow-up postpartum were retrospectively reviewed. RESULTS: Via multivariate analysis, women on opioid maintenance therapy (OMT) were more likely to continue in treatment and maintain custody, whereas women enrolled in a residential treatment program during pregnancy were less likely to continue in treatment or maintain custody. Women who continued in treatment were significantly more likely to maintain custody of their children than those who did not. CONCLUSIONS: Continuation in treatment and maintenance of custody were closely related. Care providers should attempt to improve both outcomes.

Correction to: Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members.

The Disclosures in the original article are incomplete. Not included is the following information.

Defining Weight Loss After Bariatric Surgery: a Call for Standardization.

BACKGROUND: Some weight regain is expected after bariatric surgery; however, this concept is not well defined. A favorable weight loss response has commonly been defined as 50% excess weight loss (EWL). The medical literature uses %total weight loss (%TWL), which has recently been adopted in some surgical literature. OBJECTIVE: To demonstrate variability in bariatric surgery outcomes based on the definition applied and propose a standardized definition. METHODS: A retrospective review of patients who underwent bariatric surgery from 2001 to 2016 with ≥ 1 year follow-up was completed. Several previously proposed definitions of weight regain were analyzed. RESULTS: One thousand five hundred seventy-four patients met inclusion criteria. Preoperative mean body mass index (BMI) was 47.6 ± 6.4 kg/m2. Increased preoperative BMI was associated with increased mean %TWL at 2 years postoperative (29.3 ± 9.1% for BMI < 40, vs. 37.5 ± 9.5% for BMI > 60; P < 0.001). Based on %EWL, 93% of patients experienced ≥ 50% EWL by 1-2 years, and 61.8% maintained ≥ 50% EWL through the 10-year follow-up period. Similarly, 97% experienced ≥ 20% TWL by 1-2 years and 70.3% maintained ≥ 20% TWL through the 10-year follow-up period. Over 50% of patients maintained their weight based on several proposed definitions through 5 years follow-up. CONCLUSIONS: A high percentage (> 90%) of patients achieve ≥ 20% TWL and ≥ 50% EWL. Increased preoperative BMI was associated with increased %TWL and decreased %EWL at 2 years postoperative. The incidence of weight regain varies depending on the definition. We propose a standardized definition for identifying good responders following bariatric surgery to be ≥ 20% TWL, as this measure is least influenced by preoperative BMI.