The Creation and Efforts of a Parental Task Force for Surgical Trainees.

RATIONALE AND OBJECTIONS: Surgery training often coincides with the family planning and childbearing stages of the surgeon's life. This has become especially impactful with the sharp increase in female surgical trainees. MATERIALS AND METHODS: To address important issues around family planning, our surgical department created a task force to make recommendations and create a framework as to how the department can be most supportive to surgery trainees who wish to become parents during training. RESULTS AND CONCLUSION: This article describes the efforts of the task force, which include the creation of a departmental parental handbook, a family advocacy program and a novel meeting structure designed to facilitate the successful transition to and from parental leave status.

Developing and leading a sustainable organization for early career acute care surgeons: Lessons from the inaugural American Association for the Surgery of Trauma Associate Member Council.

ABSTRACT: The associate membership of the American Association for the Surgery of Trauma (AAST) was established in 2019 to create a defined but incorporated entity within the larger AAST for the next generation of acute care surgeons. The Associate Member Council (AMC) was subsequently established in 2020 to provide the new AM with an elected group of leaders who would represent them within the AAST. In its inaugural year, this cohort of junior faculty and surgical trainees had developed for the AM a set of bylaws, a mission statement, a strategic vision, and a succession plan. The experience of the AAST AMC is exemplary of what can be accomplished with collaboration, mentorship, innovation, and tenacity. It has the potential to serve as a template for the creation and vitalization of future professional groups. In this piece, the AMC proposes a blueprint for the successful conception of a new organization.

The Impact of COVID-19 on Surgical Education.

BACKGROUND: At the onset of social distancing, our general surgery residency transitioned its educational curriculum to an entirely virtual format with no gaps in conference offerings. The aim of this study is to examine the feasibility of our evolution to a virtual format and report program attitudes toward the changes. METHODS: On March 15, 2020, due to the coronavirus disease (COVID-19) our institution restricted mass gatherings. We immediately transitioned all lectures to a virtual platform. The cancellation of elective surgeries in April 2020 then created the need for augmented resident education opportunities. We responded by creating additional lectures and implementing a daily conference itinerary. To evaluate the success of the changes and inform the development of future curriculum, we surveyed residents and faculty regarding the changes. Classes and faculty answers were compared for perception of value of the online format. RESULTS: Pre-COVID-19, residency-wide educational offerings were concentrated to one half-day per week. Once restrictions were in place, our educational opportunities were expanded to a daily schedule and averaged 16.5 hours/week during April. Overall, 41/63 residents and 25/94 faculty completed the survey. The majority of residents reported an increased ability (56%) or similar ability (34.1%) to attend virtual conferences while 9.9% indicated a decrease. Faculty responses indicated similar effects (64% increased, 32% similar, 4% decreased). PGY-1 residents rated the changes negatively compared to other trainees and faculty. PGY-2 residents reported neutral views and all other trainees and faculty believed the changes positively affected educational value. Comments from PGY1 and 2 residents revealed they could not focus on virtual conferences as it was not "protected time" in a classroom and that they felt responsible for patient care during virtual lectures. A majority of both residents (61%) and faculty (84%) reported they would prefer to continue virtual conferences in the future. CONCLUSIONS: The necessity for adapting our academic offerings during the COVID-19 era has afforded our program the opportunity to recognize the feasibility of virtual platforms and expand our educational offerings. The majority of participants report stable to improved attendance and educational value. Virtual lectures should still be considered protected time in order to maximize the experience for junior residents.

Prevention of Firearm Violence Through Specific Types of Community-based Programming: An Eastern Association for the Surgery of Trauma Evidence-based Review.

OBJECTIVE: The purpose of this review was to provide an evidence-based recommendation for community-based programs to mitigate gun violence, from the Eastern Association for the Surgery of Trauma (EAST). SUMMARY BACKGROUND DATA: Firearm Injury leads to >40,000 annual deaths and >115,000 injuries annually in the United States. Communities have adopted culturally relevant strategies to mitigate gun related injury and death. Two such strategies are gun buyback programs and community-based violence prevention programs. METHODS: The Injury Control and Violence Prevention Committee of EAST developed Population, Intervention, Comparator, Outcomes (PICO) questions and performed a comprehensive literature and gray web literature search. Using GRADE methodology, they reviewed and graded the literature and provided consensus recommendations informed by the literature. RESULTS: A total of 19 studies were included for analysis of gun buyback programs. Twenty-six studies were reviewed for analysis for community-based violence prevention programs. Gray literature was added to the discussion of PICO questions from selected websites. A conditional recommendation is made for the implementation of community-based gun buyback programs and a conditional recommendation for community-based violence prevention programs, with special emphasis on cultural appropriateness and community input. CONCLUSIONS: Gun violence may be mitigated by community-based efforts, such as gun buybacks or violence prevention programs. These programs come with caveats, notably community cultural relevance and proper support and funding from local leadership.Level of Evidence: Review, Decision, level III.

Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes.

BACKGROUND: Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes. METHODS: We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters. RESULTS: We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes. CONCLUSION: Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial.

OBJECTIVES: The mortality of patients with Clostridium difficile-associated disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single-center study. To date, no reproducible results have been published. The objective of this study was to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need. METHODS: This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma. Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture tool to store the data. Mann-Whitney (continuous data) and Fisher exact (categorical data) were used to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type. RESULTS: We collected data from 10 centers of patients who presented with CDAD requiring surgery between July 1, 2010 and July 30, 2014. Two patients died during the surgical procedure, leaving 98 individuals in the study. The overall mortality was 32%, and 75% had postoperative complications. Median age was 64.5 years; 59% were male. Concerning preoperative patient conditions, 54% were on pressors, 47% had renal failure, and 36% had respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate preprocedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC, 22 vs LI, 16). Adjusted mortality (controlled for preprocedure confounders) was significantly lower in the LI group (17.2% vs 39.7%; p = 0.002). CONCLUSIONS: This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study, LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD. LEVEL OF EVIDENCE: Therapeutic study, level III.

Helmet use is associated with safer bicycling behaviors and reduced hospital resource use following injury.

BACKGROUND: While the efficacy of helmet use in the prevention of head injury is well described, helmet use as it relates to bicyclists' behaviors and hospital resource use following injury is less defined. The objective of this study was to compare the demographics, behaviors, hospital workups, and outcomes of bicyclists based on helmet use. METHODS: This study was a subset analysis of a 2.5-year prospective cohort study of vulnerable roadway users conducted at Bellevue Hospital Center, a New York City Level 1 trauma center. All bicyclists with known helmet status were included. Demographics, insurance type, traffic law compliance, alcohol use, Glasgow Coma Scale (GCS) score, initial imaging studies, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), admission status, length of stay, disposition, and mortality were assessed. Information was obtained primarily from patients; witnesses and first responders provided additional information. RESULTS: Of 374 patients, 113 (30.2%) were wearing helmets. White bicyclists were more likely to wear helmets; black bicyclists were less likely (p = 0.037). Patients with private insurance were more likely to wear helmets, those with Medicaid or no insurance were less likely (p = 0.027). Helmeted bicyclists were more likely to ride with the flow of traffic (97.2%) and within bike lanes (83.7%) (p < 0.001 and p = 0.013, respectively). Nonhelmeted bicyclists were more likely to ride against traffic flow (p = 0.003). There were no statistically significant differences in mean GCS score, AIS score, and mean ISS for helmeted versus nonhelmeted bicyclists. Nonhelmeted patients were more likely to have head computed tomographic scans (p = 0.049) and to be admitted (p = 0.030). CONCLUSION: Helmet use is an indicator of safe riding practices, although most injured bicyclists do not wear them. In this study, helmet use was associated with lower likelihood of head CTs and admission, leading to less hospital resource use. Injured riders failing to wear helmets should be targeted for educational programs. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Clinical and therapeutic implications of Sprouty2 feedback dysregulation in BRAF V600E-mutation-positive papillary thyroid cancer.

BACKGROUND: The BRAF V600E (BRAF+) mutation activates the mitogen-activated protein kinase (MAPK/ERK) pathway and may confer an aggressive phenotype in papillary thyroid cancer (PTC). Clinically, the behavior of BRAF+ PTC, however, varies from an indolent to an aggressive course. SPRY2 is a negative feedback regulator of the MAPK/ERK pathway. We hypothesize that the level of SPRY2 expression contributes to MAPK/ERK pathway output and accounts for BRAF+ and clinical heterogeneity. METHODS: A tissue microarray with BRAF-positive PTCs (BRAF+ PTCs) was constructed and analyzed for SPRY2 expression and MAPK/ERK output. Data were studied in the context of clinicopathologic factors to develop a risk stratification system predictive of tumor biology. SPRY2 function was studied by silencing SPRY2 in BRAF+ PTC cells. These cells were treated with MAPK/ERK pathway inhibitors and assessed for growth effects. RESULTS: BRAF+ PTCs with an intact MAPK/ERK feedback pathway do not exhibit lymph node metastases. BRAF+ PTCs with dysregulated feedback pathways have nodal metastasis. When SPRY2 is silenced, the BRAF+ PTC cells are significantly more sensitive to MAPK/ERK inhibition. CONCLUSION: PTC behavior likely is dependent on both the driver of the MAPK/ERK pathway and its regulatory feedback. When the feedback pathway is intact, the tumor phenotype seems to be less aggressive. This observation has direct and important clinical implications and may alter our treatment strategies.

Vulnerable roadway users struck by motor vehicles at the center of the safest, large US city.

BACKGROUND: Road safety constitutes an international crisis. In 2010, 11,000 pedestrians and 3,500 bicyclists were injured by motor vehicles in New York City. This study aims to identify the demographics, behaviors, injuries, and outcomes of vulnerable roadway users struck by motor vehicles in New York City's congested central business district and surrounding periphery. METHODS: A prospective, descriptive study of pedestrians and bicyclists struck by motor vehicles and treated at a Level I regional trauma center was performed. Data were collected between December 2008 and June 2011 by interviewing patients and first responders supplemented with imaging and outcomes variables. Main outcome measures included patient demographics, behavior patterns, scene-related data, Injury Severity Score (ISS), and outcomes including mortality. Multivariate ordinal logistic regression modeling was performed to isolate effects of predictor variables on outcome of ISS categories. RESULTS: Injured pedestrians (n = 1,075) and bicyclists (n = 382) differ by age (p < 0.001), sex (p < 0.001), ethnicity/race (p < 0.001), and involved motor vehicle type (p < 0.001). Pedestrians sustain more severe/critical injuries (p < 0.001) and hospital admissions (p < 0.001). Bicyclists are more commonly struck by taxis (p < 0.001) and infrequently wear helmets (29.6%). Variables associated with low ISS include bicycling (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.29-0.63), above normal body mass index (AOR, 0.73; 95% CI, 0.54-0.99), Latino (AOR, 0.65; 95% CI, 0.46-0.94) or black (AOR, 0.63; 95% CI, 0.41-0.96) ethnicity/race, and struck by a taxicab (AOR, 0.50; 95% CI, 0.33-0.76) or turning vehicle (AOR,0.49; 95% CI, 0.34-0.70). Variables associated with high ISS include alcohol (AOR, 2.71; 95% CI, 1.81-4.05), age less than 18 years (AOR, 1.73; 95% CI, 1.05-2.86), hearing impairment (AOR, 2.24; 95% CI, 1.24-4.03), and struck by a truck or bus (AOR, 1.91; 95% CI, 1.18-3.10). Mortality was 1.2%. CONCLUSION: Injured pedestrians and bicyclists represent distinct entities. Prevention modalities must be tailored accordingly with a focus on high-risk subgroups and compliance with traffic laws. Studying fatality or admissions data fail to capture the extent of the epidemic. LEVEL OF EVIDENCE: Prospective epidemiologic study, level II.

Late solitary metastasis of renal cell carcinoma to the submandibular gland.

Metastatic renal cell carcinoma to the head and neck is rare. Most reported cases of metastases to the head and neck involve the thyroid and parotid glands. Metastasis to other salivary glands is exceedingly rare. This report describes a case of a solitary metastasis of renal cell carcinoma to the submandibular gland 9 years after nephrectomy. To the authors' knowledge, this is the first case successfully diagnosed preoperatively using a combination of fine-needle aspiration and clinical history. The patient subsequently underwent a submandibular gland resection with preservation of the facial nerve branches. For the 3 years since resection of the submandibular gland, the patient has been free of disease.

In-house trauma attendings: a new financial benefit for hospitals.

BACKGROUND: There is an intuitive belief that in-house trauma attendings benefit patient outcome, although multiple studies have failed to prove this. However, no studies investigate the financial advantage for hospitals by having the attendings also perform urgent general surgery cases (GSC) during nights and weekends. The purpose of this study is to identify how an in-house attending program was used for urgent GSC and to see if it provided a financial benefit to the hospital. METHODS: The in-house program began in October 2007. A retrospective study reviewed all cholecystectomies performed from October 2006 to September 2007 and October 2007 to September 2008. Total length of stay (LOS) was calculated. Total LOS for each group was multiplied by the daily cost for a medical-surgical bed ($2,530.00). The cost difference was calculated for the pre- and post-in-house groups. RESULTS: Two hundred sixty-four cholecystectomies were performed before instituting an in-house attending program compared with 291 cases in the period after a 9% increase. Total LOS for cholecystectomies performed before the program was 6.4 days translating to $16,192.00 in room costs versus 5.24 days after and $13,257.20 in room costs. This translated to a savings of $2,934.80 per patient and $854,026.80 savings in total because of reduced LOS, which subsidized the cost of the program, which was $750,000.00. CONCLUSION: In-house attendings are beneficial in decreasing overall LOS for urgent GSC. This study demonstrates that in-house attendings can perform urgent GSCs and realize a savings for a hospital that can be used to fully subsidize the cost of the program.

Ileocecal valve lipoma with refractory hemorrhage.

BACKGROUND: Lipomas are the most common benign mesenchymal tumors of the gastrointestinal tract, with the colon being the most prevalent site. Intestinal lipomas are usually asymptomatic. Tumors >2 cm in diameter may occasionally cause nonspecific symptoms, including change in bowel habits, abdominal pain, or rectal bleeding, but with resection the prognosis is excellent. Herein, we describe the case of an elderly male who presented with painless hematochezia. METHODS: Both colonoscopy and computed tomography of the abdomen and pelvis confirmed the presence of a mass near the ileocecal valve. Because of continuing bleeding, the patient required laparoscopic-assisted right hemicolectomy to resect the mass. RESULTS: Both gross and microscopic pathology were consistent with lipoma at the ileocecal valve. CONCLUSION: Previous cases of ileocecal valve lipomas have been reported in the English literature, with the majority presenting as intussusception or volvulus. We present a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection.