Cutis Laxa Acquisita After Urticarial Vasculitis in SLE Patients.

Cutis laxa is a rare connective tissue disease involving damage to dermal elastic fibers creating a clinical appearance of loose, sagging skin. The condition can be either acquired or genetic. Autoimmune diseases, neoplasms, infections, and medications have been proposed as the cause of, or in association with, the acquired form. In nearly 50% of cases, erythematous plaques present before the onset of cutis laxa. Separately, urticarial vasculitis and systemic lupus erythematosus have been linked to cutis laxa acquisita. Our case is the first in the literature documenting a coexistence of cutis laxa acquisita, hypocomplementemic urticarial vasculitis, and systemic lupus erythematosus.

Contemporary Evaluation of Work-Life Integration and Wellbeing in US Surgical Residents: A National Mixed-Methods Study.

BACKGROUND: The demands of surgical training present challenges for work-life integration (WLI). We sought to identify factors associated with work-life conflicts and to understand how programs support WLI. STUDY DESIGN: A cross-sectional national survey conducted after the 2020 American Board of Surgery In-Training Examination queried 4 WLI items. Multivariable regression models evaluated factors associated with (1) work-life conflicts and (2) well-being (career dissatisfaction, burnout, thoughts of attrition, suicidality). Semi-structured interviews conducted with faculty and residents from 15 general surgery programs were analyzed to identify strategies for supporting WLI. RESULTS: Of 7,233 residents (85.5% response rate) 5,133 had data available on work-life conflicts. 44.3% reported completing non-educational task-work at home, 37.6% were dissatisfied with time for personal life (e.g., hobbies), 51.6% with maintaining healthy habits (e.g., exercise), and 48.0% with performing routine health maintenance (e.g., dentist). In multivariable analysis, parents and female residents were more likely to report work-life conflicts (all p<0.05). After adjusting for other risk factors (e.g., duty-hour violations, and mistreatment), residents with work-life conflicts remained at increased risk for career dissatisfaction, burnout, thoughts of attrition, and suicidality (all p<0.05). Qualitative analysis revealed interventions for supporting WLI including (1) protecting time for health maintenance (e.g., therapy); (2) explicitly supporting life outside of work (e.g., prioritizing time with family); and (3) allowing meaningful autonomy in scheduling (e.g., planning for major life events). CONCLUSIONS: Work-life conflicts are common among surgical residents and are associated with poor resident well-being. Well-designed program-level interventions have the potential to support WLI in surgical residency.

Addressing Surgeon Burnout Through a Multi-level Approach: A National Call to Action.

Purpose of Review: Physician burnout is an epidemic and there are unique aspects of surgery that dictate rates of burnout among general surgeons and surgical trainees. This review characterizes the scope of burnout and its drivers within the field of surgery and advocates for strategies to address burnout at the individual, institutional, and national levels. Recent Findings: Rates of burnout in surgery are increasing with higher numbers of young and female surgeons affected. Contributing factors are generally related to work-life balance, longer hours, and mistreatment in the workplace. Attempts have been made at implementing structured initiatives in an effort to combat work dissatisfaction and emotional exhaustion. Still, rates of burnout continue to increase. Summary: General surgeons and trainees are at high risk for burnout with resulting attrition, depression, and suicidal ideation. The solution to burnout must be addressed at individual, institutional, and national levels. Further research into the factors leading to surgeon burnout and enactment of effective strategies to mitigate burnout must be pursued.

Autonomy Maps: Building a Shared Mental Model for Progressive Resident Operative Autonomy on the Road to Entrustable Professional Activities (EPAs).

Our residents expressed dissatisfaction with operative autonomy and faculty feedback regarding technical skills. They reported variability among faculty regarding allowed operative autonomy. Our goals were to establish a shared mental model among residents and faculty regarding intraoperative performance expectations. We asked faculty to assign a level of expected autonomy (Zwisch scale) for various steps of common procedures according to the resident post-graduate year. Through an iterative process, the maps were standardized across service lines. The resulting "Autonomy Maps" were distributed to the faculty and residents. We held educational sessions and set expectations for use. Selected benchmarks were incorporated into resident end-of-rotation assessment forms. Initial operative case mapping identified variability in faculty expectations for a given post-graduate year and procedure. Residents reported improved satisfaction with understanding expectations regarding operative performance. Establishing autonomy benchmarks facilitated more specific feedback regarding residents' technical skills. Faculty expectations for resident operative autonomy are variable. Autonomy Maps provide structure for a shared mental model between faculty and residents for progressive operative autonomy and serve as a framework for expectations that improve resident satisfaction. Case-specific technical benchmarks are useful tools for assessing residents' technical milestones.

Pancreatic Cancer Lymph Node Resection Revisited: A Novel Calculation of Number of Lymph Nodes Required.

BACKGROUND: Pancreatic cancer is the third leading cause of cancer related deaths in the US. Although lymph node (LN) metastasis is a prognostic indicator, the extent of LN resection is still debated. Our goal was to use the distribution of the ratio of positive to negative LNs to derive a more adequate number of necessary examined LNs based on the target LN threshold (TLNT). STUDY DESIGN: Using the National Cancer Database, we performed a retrospective study of surgically resected pancreatic adenocarcinoma (2010 to 2015). We evaluated the number of positive LNs and total LNs examined and the log of the ratio of positive LNs to negative LNs (LODDS). The distribution of LODDS was examined to determine a target LNs examined threshold sufficient to detect N1 disease. Using the LODDS distribution of N1 cases, target LNs examined threshold were calculated to encompass 90 of the N1 group distribution. RESULTS: Of the total 24,038 resected patients included in this study, 26% underwent operation only, 18% received neoadjuvant therapy, and 56% underwent adjuvant therapy. In all, 8,144 (34%) patients had N0 disease and 15,894 (66%) had N1 disease. To capture 90% to 95% of the N1 group, the minimum number of LNs examined would be 18 (LODDS -2.74) to 24 (LODDS -3.04), respectively. CONCLUSIONS: Although previous studies have suggested 11 to 17 LNs required for adequate LN sampling in pancreatic cancer, our findings suggest that to capture 90% of cases with N1 disease, 18 LNs is more appropriate.

Procedural-Memory, Working-Memory, and Declarative-Memory Skills Are Each Associated With Dimensional Integration in Sound-Category Learning.

This paper investigates relationships between procedural-memory, declarative-memory, and working-memory skills and adult native English speakers' novel sound-category learning. Participants completed a sound-categorization task that required integrating two dimensions: one native (vowel quality), one non-native (pitch). Similar information-integration category structures in the visual and auditory domains have been shown to be best learned implicitly (e.g., Maddox et al., 2006). Thus, we predicted that individuals with greater procedural-memory capacity would better learn sound categories, because procedural memory appears to support implicit learning of new information and integration of dimensions. Seventy undergraduates were tested across two experiments. Procedural memory was assessed using a linguistic adaptation of the serial-reaction-time task (Misyak et al., 2010a,b). Declarative memory was assessed using the logical-memory subtest of the Wechsler Memory Scale-4th edition (WMS-IV; Wechsler, 2009). Working memory was assessed using an auditory version of the reading-span task (Kane et al., 2004). Experiment 1 revealed contributions of only declarative memory to dimensional integration, which might indicate not enough time or motivation to shift over to a procedural/integrative strategy. Experiment 2 gave twice the speech-sound training, distributed over 2 days, and also attempted to train at the category boundary. As predicted, effects of declarative memory were removed and effects of procedural memory emerged, but, unexpectedly, new effects of working memory surfaced. The results may be compatible with a multiple-systems account in which declarative and working memory facilitate transfer of control to the procedural system.

Cerebral Aneurysms Differ in Patients with Hysterectomies.

OBJECTIVE: Female sex is a well-known risk factor for aneurysm formation. Although the role of the ovaries and estrogen in aneurysm development has been supported, other organ-hormone pairs unique between sexes also may be implicated. In this study, we aimed to determine whether intracranial aneurysms microsurgically clipped in patients with previous hysterectomies exhibit any unique aneurysm characteristics from those without hysterectomies. METHODS: Solitary aneurysms microsurgically treated by the senior author (M.T.L.) were included from a database of patients treated between January 2010 and April 2013 at a tertiary academic medical center. Only female patients and patients equal or older in age to the youngest patient in the hysterectomy group were included in the control group. Patient and aneurysm characteristics were compared using the χ2 test for categorical variables and the independent t test analysis for continuous variables. RESULTS: A total 233 patients were included in the study. Forty-three patients (19%) had undergone a previous hysterectomy; none had oophorectomies recorded. No difference in mean age (P = 0.89), hypertension (P = 0.38), alcohol use (P = 0.87), tobacco use (P = 0.22), or aneurysm location (P = 1) existed. However, patients in the hysterectomy group more often presented in a good neurologic condition before surgery (88% vs. 74%, P = 0.04) and had fewer large aneurysms (8% vs. 24%, P = 0.03). Also, fewer presented with a ruptured aneurysm (28%) then the nonhysterectomy group (51%) (P = 0.004). CONCLUSIONS: Female patients with a surgical history of a hysterectomy have a lower rate of large aneurysms, present in better neurologic condition, and are less likely to present with a ruptured aneurysm than females without a hysterectomy.

Baseline clinical characteristics predict follow-up clinic attendance in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis.

BACKGROUND: The objective of this work was to describe the association between baseline clinical characteristics and attendance at follow-up visits after endoscopic sinus surgery (ESS). METHODS: A retrospective review of chronic rhinosinusitis (CRS) patients electing ESS at a tertiary-care center (2011-2013) was conducted. Baseline characteristics were studied for association with clinic attendance at 3, 6, 12, and 24 months post-ESS. RESULTS: We identified 268 patients. Significant decline occurred in the number of patients following up after ESS (3 months: 246 patients [92%]; 6 months: 145 [54%]; 12 months: 94 [35%]; and 24 months: 90 [34%]). Older patients were more likely to follow up at 3 months (mean age 55.7 vs 48.4 years, p = 0.04) and 6 months (57.5 vs 52.3 years; p = 0.01) post-ESS. Those with higher preoperative sinus computed tomography (CT) (Lund-Mackay) scores were more likely to follow at 6 months (11.8 vs 10.3, p = 0.01), 12 months (12.6 vs 10.3, p < 0.001), and 24 months (12.2 vs 10.5, p = 0.01). At 12 months having asthma (p = 0.03), previous ESS (p = 0.04), nasal polyps (p < 0.0001), allergic fungal sinusitis (AFS) (p = 0.002), and granulomatosis with polyangiitis (GPA) (p = 0.01) were associated with clinic attendance. At 24 months asthma status (p = 0.003), previous ESS (p = 0.002), AFS (p = 0.04), GPA (p = 0.001), and aspirin-exacerbated respiratory disease (AERD) (p = 0.006) were associated with higher attendance. Geographical proximity did not impact attendance. CONCLUSION: The sharpest decline in patient follow-up occurred between 3-6 months after ESS. Higher preoperative sinus CT scores, previous ESS, presence of asthma, and diagnosis of recalcitrant CRS subtype (nasal polyps, AERD, AFS, GPA) were factors associated with increased long-term attendance.

Gender-specific analysis of outcomes from endoscopic sinus surgery for chronic rhinosinusitis.

BACKGROUND: Women electing endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) report higher symptom burden but have lower computed tomography (CT) scores. Gender-specific analysis of outcomes from ESS therefore merits further study. The objective of this work was to study gender-specific differences in outcomes from ESS for CRS by analyzing preoperative and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores. METHODS: Data from adult CRS patients electing ESS (2011-2013) were retrospectively collected. SNOT-22 total, rhinologic/nonrhinologic subdomain, and individual item scores were analyzed for gender-specific differences. RESULTS: Two hundred and forty-eight patients met study criteria (mean age 55.4 years; 49.6% female). Preoperatively, mean Lund-Mackay CT score was 11.1; average total SNOT-22 score was 41.9. Compared to men, women had lower CT score (10.2 vs 12.0; p = 0.004) but higher total SNOT-22 score (44.7 vs 39.1; p = 0.02). Both genders showed significant improvement in total SNOT-22 scores at 3, 6, 12, and 24 months following ESS (p < 0.001), with largely similar slopes of improvement. The greatest improvement occurred at 3 months (SNOT-22 decreased by 25.4 points), with stable improvement after 12 months (SNOT-22 decreased by 21.3 points). Higher total SNOT-22 scores in females were noted preoperatively and until 6 months post-ESS; these were driven by rhinologic and nonrhinologic-otolaryngic subdomain items. No gender differences in anxiety/depression prevalence or psychological subdomain scores were noted preoperatively or postoperatively. CONCLUSION: Both male and female CRS patients showed significant and durable symptom relief following ESS. Women reported higher symptom burden prior to surgery, and in the early postoperative period. However, after 1-year post-ESS, both genders showed similar symptom scores. The trend and magnitude of improvement were similar in both genders.