The Reconstructive Metaverse - Collaboration in Real-Time Shared Mixed Reality Environments for Microsurgical Reconstruction.

Plastic surgeons routinely use 3D-models in their clinical practice, from 3D-photography and surface imaging to 3D-segmentations from radiological scans. However, these models continue to be viewed on flattened 2D screens that do not enable an intuitive understanding of 3D-relationships and cause challenges regarding collaboration with colleagues. The Metaverse has been proposed as a new age of applications building on modern Mixed Reality headset technology that allows remote collaboration on virtual 3D-models in a shared physical-virtual space in real-time. We demonstrate the first use of the Metaverse in the context of reconstructive surgery, focusing on preoperative planning discussions and trainee education. Using a HoloLens headset with the Microsoft Mesh application, we performed planning sessions for 4 DIEP-flaps in our reconstructive metaverse on virtual patient-models segmented from routine CT angiography. In these sessions, surgeons discuss perforator anatomy and perforator selection strategies whilst comprehensively assessing the respective models. We demonstrate the workflow for a one-on-one interaction between an attending surgeon and a trainee in a video featuring both viewpoints as seen through the headset. We believe the Metaverse will provide novel opportunities to use the 3D-models that are already created in everyday plastic surgery practice in a more collaborative, immersive, accessible, and educational manner.

HoloDIEP-Faster and More Accurate Intraoperative DIEA Perforator Mapping Using a Novel Mixed Reality Tool.

BACKGROUND: Microsurgical breast reconstruction using abdominal tissue is a complex procedure, in part, due to variable vascular/perforator anatomy. Preoperative computed tomography angiography (CTA) has mitigated this challenge to some degree; yet it continues to pose certain challenges. The ability to map perforators with Mixed Reality has been demonstrated in case studies, but its accuracy has not been studied intraoperatively. Here, we compare the accuracy of "HoloDIEP" in identifying perforator location (vs. Doppler ultrasound) by using holographic 3D models derived from preoperative CTA. METHODS: Using a custom application on HoloLens, the deep inferior epigastric artery vascular tree was traced in 15 patients who underwent microsurgical breast reconstruction. Perforator markings were compared against the 3D model in a coordinate system centered on the umbilicus. Holographic- and Doppler-identified markings were compared using a perspective-corrected photo technique against the 3D model along with measurement of duration of perforator mapping for each technique. RESULTS: Vascular points in HoloDIEP skin markings were -0.97 ± 6.2 mm (perforators: -0.62 ± 6.13 mm) away from 3D-model ground-truth in radial length from the umbilicus at a true distance of 10.81 ± 6.14 mm (perforators: 11.40 ± 6.15 mm). Absolute difference in radial distance was twice as high for Doppler markings compared with Holo-markings (9.71 ± 6.16 and 4.02 ± 3.20 mm, respectively). Only in half of all cases (7/14), more than 50% of the Doppler-identified points were reasonably close (<30 mm) to 3D-model ground-truth. HoloDIEP was twice as fast as Doppler ultrasound (76.9s vs. 150.4 s per abdomen). CONCLUSION: HoloDIEP allows for faster and more accurate intraoperative perforator mapping than Doppler ultrasound.

Climate change and human health in the Eastern Mediterranean and Middle East: Literature review, research priorities and policy suggestions.

Human health is linked to climatic factors in complex ways, and climate change can have profound direct and indirect impacts on the health status of any given region. Susceptibility to climate change is modulated by biological, ecological and socio-political factors such as age, gender, geographic location, socio-economic status, occupation, health status and housing conditions, among other. In the Eastern Mediterranean and Middle East (EMME), climatic factors known to affect human health include extreme heat, water shortages and air pollution. Furthermore, the epidemiology of vector-borne diseases (VBDs) and the health consequences of population displacement are also influenced by climate change in this region. To inform future policies for adaptation and mitigation measures, and based on an extensive review of the available knowledge, we recommend several research priorities for the region. These include the generation of more empirical evidence on exposure-response functions involving climate change and specific health outcomes, the development of appropriate methodologies to evaluate the physical and psychological effects of climate change on vulnerable populations, determining how climate change alters the ecological determinants of human health, improving our understanding of the effects of long-term exposure to heat stress and air pollution, and evaluating the interactions between adaptation and mitigation strategies. Because national boundaries do not limit most climate-related factors expected to impact human health, we propose that adaptation/mitigation policies must have a regional scope, and therefore require collaborative efforts among EMME nations. Policy suggestions include a decisive region-wide decarbonisation, the integration of environmentally driven morbidity and mortality data throughout the region, advancing the development and widespread use of affordable technologies for the production and management of drinking water by non-traditional means, the development of comprehensive strategies to improve the health status of displaced populations, and fostering regional networks for monitoring and controlling the spread of infectious diseases and disease vectors.

Complication Rates in Therapeutic Versus Prophylactic Bilateral Mastectomies: Insights From a National Database.

BACKGROUND: The "Jolie effect" and other media focus on prophylactic treatments have resulted in unilateral breast cancer patients increasingly undergoing contralateral prophylactic mastectomy. Little is known, however, regarding outcomes following therapeutic versus prophylactic mastectomy. In this study, we compared complication rates of unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (BM-TP) to patients undergoing bilateral prophylactic mastectomy (BM-P). METHODS: The BM-TP and BM-P patients from 2015 to 2019 were identified in Optum Clinformatics DataMart. Six-month outcomes were assessed and included wound complications, infection, hematoma/seroma, breast pain, fat necrosis, flap failure, implant failure/removal, other flap/implant complications, and other complications. Multivariable regression models adjusted for age, residence, insurance, race, and Charlson Comorbidity Index score. RESULTS: Of 9319 women, 7114 (76.3%) underwent BM-TP, and 2205 (23.7%) underwent BM-P. In multivariable analysis, BM-TP had higher odds of overall complications (adjusted odds ratio [aOR], 1.35; P < 0.0001), but no difference was observed among patients who had autologous ( P = 0.1448) or no breast reconstruction ( P = 0.1530). Higher odds of overall complications persisted even after controlling for radiation therapy (aOR, 1.25; P = 0.0048) and chemotherapy (aOR, 1.28; P = 0.0047), but not after controlling for lymph node surgery ( P = 0.7765). CONCLUSION: The BM-TP (vs BM-P) patients face higher odds of overall complications but without any difference in certain reconstructive modalities or after controlling for lymph node surgery.

Comparing the Outcomes and Complication Rates of Biologic vs Synthetic Meshes in Implant-Based Breast Reconstruction: A Systematic Review.

OBJECTIVE: This systematic review evaluates all published studies comparing biologic and synthetic meshes in implant-based breast reconstruction (IBBR), to determine which category of mesh produces the most favorable outcomes. SUMMARY BACKGROUND DATA: Breast cancer is the most common cancer in women globally. Implant-based breast reconstruction is currently the most popular method of postmastectomy reconstruction, and recently, the use of surgical mesh in IBBR has become commonplace. Although there is a long-standing belief among surgeons that biologic mesh is superior to synthetic mesh in terms of surgical complications and patient outcomes, few studies exist to support this claim. METHODS: A systematic search of the EMBASE, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies comparing biologic and synthetic meshes within the same experimental framework were included. Study quality and bias were assessed using the validated Methodological Index for Non-Randomized Studies criteria. RESULTS: After duplicate removal, 109 publications were reviewed, with 12 meeting the predetermined inclusion criteria. Outcomes included common surgical complications, histological analysis, interactions with oncologic therapies, quality of life measures, and esthetic outcomes. Across all 12 studies, synthetic meshes were rated as at least equivalent to biologic meshes for every reported outcome. On average, the studies in this review tended to have moderate Methodological Index for Non-Randomized Studies scores. CONCLUSION: This systematic review offers the first comprehensive evaluation of all publications comparing biologic and synthetic meshes in IBBR. The consistent finding that synthetic meshes are at least equivalent to biologic meshes across a range of clinical outcomes offers a compelling argument in favor of prioritizing the use of synthetic meshes in IBBR.

Randomized Trial of Spheroid Reservoir Bioartificial Liver in Porcine Model of Posthepatectomy Liver Failure.

Acute liver failure (ALF) is a catastrophic condition that can occur after major liver resection. The aim of this study was to determine the effects of the spheroid reservoir bio-artificial liver (SRBAL) on survival, serum chemistry, and liver regeneration in posthepatectomy ALF pigs. Wild-type large white swine (20 kg-30 kg) underwent intracranial pressure (ICP) probe placement followed by 85% hepatectomy. Computed tomography (CT) volumetrics were performed to measure the extent of resection, and at 48 hours following hepatectomy to assess regeneration of the remnant liver. Animals were randomized into three groups based on treatment delivered 24-48 hours after hepatectomy: Group1-standard medical therapy (SMT, n = 6); Group2-SMT plus bio-artificial liver treatment using no hepatocytes (0 g, n = 6); and Group3-SMT plus SRBAL treatment using 200 g of primary porcine hepatocyte spheroids (200 g, n = 6). The primary endpoint was survival to 90 hours following hepatectomy. Death equivalent was defined as unresponsive grade 4 hepatic encephalopathy or ICP greater than 20 mmHg with clinical evidence of brain herniation. All animals in both (SMT and 0 g) control groups met the death equivalent before 51 hours following hepatectomy. Five of 6 animals in the 200-g group survived to 90 hours (P < 0.01). The mean ammonia, ICP, and international normalized ratio values were significantly lower in the 200-g group. CT volumetrics demonstrated increased volume regeneration at 48 hours following hepatectomy in the 200-g group compared with the SMT (P < 0.01) and 0-g (P < 0.01) groups. Ki-67 staining showed increased positive staining at 48 hours following hepatectomy (P < 0.01). Conclusion: The SRBAL improved survival, reduced ammonia, and accelerated liver regeneration in posthepatectomy ALF. Improved survival was associated with a neuroprotective benefit of SRBAL therapy. These favorable results warrant further clinical testing of the SRBAL.

Association of asthma with osteopenia, osteoporosis, osteomalacia, and fractures.

Background: Previous studies that examined the relationship between asthma, osteoporosis, and pathologic fractures found conflicting results. Objective: To determine whether asthma is associated with osteopenia, osteoporosis, osteomalacia, and fractures in U.S. adults. Methods: A cross-sectional study of 198,102,435 children and adults, including 10,129,307 with asthma, from the 2006-2012 National Emergency Department Sample, which includes a representative 20% sample of emergency department (ED) visits throughout the United States. Results: ED visits of patients with versus without asthma were associated with higher odds of osteopenia (7 of 7 years: multivariable logistic regression of all years pooled; adjusted odds ratio [aOR] 1.45 [95% confidence interval {CI}, 1.41-1.50]), osteoporosis (7 of 7 years: aOR 1.85 [95% CI, 1.82-1.88]), osteomalacia (7 of 7 years: aOR 2.00 [95% CI, 1.61-2.49]), and pathologic fractures (7 of 7 years: OR 1.24 [95% CI, 1.20-1.27]). Patients with asthma and with long-term glucocorticoid use had higher odds of osteoporosis, osteopenia, osteomalacia, and fractures compared with patients with asthma and without long-term glucocorticoid use. Patients with asthma and with fractures incurred significantly more inpatient admissions, and higher costs of ED and inpatient care. Conclusion: ED visits with asthma were associated with osteopenia, osteoporosis, osteomalacia, and pathologic fractures.

Cold storage of porcine hepatocyte spheroids for spheroid bioartificial liver.

BACKGROUND AND AIMS: Cell-based therapies for liver disease such as bioartificial liver rely on a large quantity and high quality of hepatocytes. Cold storage was previously shown to be a better way to preserve the viability and functionality of hepatocytes during transportation rather than freezing, but this was only proved at a lower density of rat hepatocytes spheroids. The purpose of this study was to optimize conditions for cold storage of high density of primary porcine hepatocyte spheroids. METHODS: Porcine hepatocytes were isolated by a three-step perfusion method; hepatocyte spheroids were formed by a 24 hours rocked culture technique. Hepatocyte cell density was 5 × 106 /mL in 1000 mL spheroid forming medium. Spheroids were then maintained in rocked culture at 37°C (control condition) or cold stored at 4°C for 24, 48 or 72 hours in four different cold storage solutions: histidine-tryptophan-ketoglutarate (HTK) alone; HTK + 1 mM deferoxamine (DEF); HTK + 5 mM N-acetyl-L-cysteine (NAC); and HTK + 1 mM DEF + 5 mM NAC. The viability, ammonia clearance, albumin production, gene expression, and functional activity of cytochrome P450 enzymes were measured after recovery from the cold storage. RESULTS: In this study, we observed that cold-induced injury was reduced by the addition of the iron chelator. Viability of HTK + DEF group hepatocyte spheroids was increased compared with other cold storage groups (P < 0.05). Performance metrics of porcine hepatocyte spheroids cold stored for 24 hours were similar to those in control conditions. The hepatocyte spheroids in control conditions started to lose their ability to clear ammonia while production of albumin was still active at 48 and 72 hours (P < 0.05). In contrast, the viability and functionality of hepatocyte spheroids including ammonia clearance and albumin secretion were preserved in HTK + DEF group at both 48- and 72-hour time points (P < 0.05). CONCLUSIONS: The beneficial effects of HTK supplemented with DEF were more obvious after cold storage of high density of porcine hepatocyte spheroids for 72 hours. The porcine hepatocyte spheroids were above the cutoff criteria for use in a spheroid-based bioartificial liver.

Health risk behaviours of Palestinian youth: findings from a representative survey.

BACKGROUND: There is little systematic information about health risk behaviours among youth in Middle Eastern countries, leaving public health authorities unprepared to deal with emerging public health threats at a time of major social change. AIM: The Palestinian Youth Health Risk study investigates patterns of risk behaviours among Palestinian youth, their perceptions of the risks and benefits of such behaviours, and the relationship of exposure to violence with mental health and engagement in risk behaviours. METHODS: We conducted a representative survey among 2500 individuals aged 15-24 years in the West Bank and East Jerusalem, permitting reliable comparison across sex and rural-urban divisions. A stratified 2-stage random sample was drawn from the 2007 population census, with strata formed by crossing the 12 governorates with urban, rural and refugee camp locations. Within strata, 208 survey clusters were sampled with probability proportional to size. Within each cluster, 14 households with youth of the appropriate age were sampled. RESULTS: Among youth aged 20-24 years, 22.4% of males and 11.6% of females reported trying alcohol; 10.5% of males and 4.3% of females reported trying drugs. Almost one quarter of unmarried youth aged 20-24 years reported any sexual experience. Tobacco use is high, even among younger youth (45.4% of males and 21.2% of females aged 15-19 smoke). Risk behaviours are higher among males, older youth and in urban areas and refugee camps. CONCLUSION: While smoking is of particular concern, prevention outreach for all behaviours should be directed at subgroups and areas identified as highest risk.

Substance use among Palestinian youth in the West Bank, Palestine: a qualitative investigation.

BACKGROUND: Youth health risk behaviors, including substance use (psychoactive substances including alcohol and illicit drugs), have been the subject of relatively limited study to date in Middle Eastern countries. This study provides insights into the perceived prevalence and patterns of alcohol and drug use among Palestinian youth. METHODS: The study was based on ten focus groups and 17 individual interviews with youth aged 16-24 years (n = 83), collected as part of the formative phase of a cross-sectional, population representative study of risk taking behaviors among Palestinian youth in the West Bank in 2012. Qualitative analysis was used to code detailed notes of focus groups and interviews. RESULTS: Most participants reported that substance use exists, even in socially conservative communities. Almost all participants agreed that alcohol consumption is common and that alcohol is easily available. The top alcoholic drinks referred to by the study participants were vodka, whisky, beer, and wine. Most participants claimed that they drink alcohol to cope with stress, for fun, out of curiosity, to challenge society, and due to the influence of the media. Participants were familiar with illicit drugs and knew of youth who engaged in drug use: marijuana, cocaine, and heroin were mentioned most frequently. Study participants believed that youth use drugs as a result of stress, the Israeli occupation, inadequate parental control, lack of awareness, unhappiness, curiosity, and for entertainment. Many participants were unaware of any local institutions to support youth with substance use problems. Others expressed their distrust of any such institution as they assumed them to be inefficient, profit-driven, and posing the risk of potential breaches of confidentiality. CONCLUSIONS: Although this study uses a purposive sample, the results suggest that substance use exists among Palestinian youth. Risk behaviors are a concern given inadequate youth-friendly counseling services and the strong cultural constraints on open discussion or education about the impact of high risk behaviors. These barriers to treatment and counseling can exacerbate the health and social consequences of alcohol abuse and illicit drug use.

Elimination of 24-hour continuous medical resident duty in Quebec.

SUMMARY: In 2012 Quebec limited continuous in-hospital duty to 16 consecutive hours for all residents regardless of postgraduate (PGY) level. The new restrictions in Quebec appeared to have a profound, negative effect on the quality of life of surgical residents at McGill University and a perceived detrimental effect on the delivery of surgical education and patient care. Here we discuss the results of a nationwide survey that we created and distributed to general surgery residents across Canada to capture and compare their perceptions of the changes to duty hour restrictions.

Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients.

The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.

Perceptions of sexual risk behavior among Palestinian youth in the West Bank: a qualitative investigation.

BACKGROUND: Young people in the Middle East and North Africa (MENA) are profoundly affected by violence, high unemployment, and economic hardship. Experiences of community-level violence and personal trauma increase the likelihood that young people will engage in risky behaviors that include smoking, drug use, and unsafe sex. Little is known about the sexual behavior of young people in the region, particularly in the occupied Palestinian territory (oPt). Our aim in this study was to gain an insight into the perceived prevalence and patterns of sexual behavior among Palestinian youth. METHODS: The study was based on ten focus groups and 17 in-depth interviews with young people aged 16-24 years as part of the formative phase of a cross-sectional representative study of risk behaviors in the West Bank, including Jerusalem, in 2012. The sample was selected using a combination of purposive and convenience sampling. Qualitative analysis was used to code detailed notes of focus groups and interviews. RESULTS: Based on participants' reports, different types of sexual activity outside marriage were not uncommon, even in conservative communities. The most reported sexual activity was non-penetrative sex: oral and anal intercourse, and virtual sex. Some young people had sexual intercourse with sex workers; they went to brothels in Israel and to brothels operating clandestinely in the West Bank, including East Jerusalem. Most respondents were of the opinion that young people did not usually use protection during sexual intercourse. Many reported that youth engage in different types of sexual activity outside marriage for several reasons: to challenge the culture, financial constraints and inability to marry, basic human need, personal pleasure, suppression, to kill boredom, and to prove manhood. CONCLUSIONS: In contrast with the conservative social context of the occupied Palestinian territory (oPt), the findings suggest that sexual activities outside marriage may be more common than is currently assumed. Sexual behavior in the oPt is a concern because of the low awareness of the potential health consequences. The results draw attention to the need to incorporate sexual reproductive health into the national agenda and ensure that it is included in the programs of national institutions.

Semi-simultaneous hand-assisted laparoscopic (HAL) bilateral nephrectomy and kidney transplantation from the same incision in ADPKD, first case report in Saudi Arabia.

This case report discusses the management of a 46-year-old male patient with autosomal dominant polycystic kidney disease and a high body mass index, who underwent a semi-simultaneous procedure involving hand-assisted laparoscopic bilateral nephrectomy to alleviate severe abdominal symptoms and prepare for a kidney transplantation, all using the same incision. This is the first reported occurrence of such a procedure in Saudi Arabia. Post-operatively, the patient made a successful recovery with excellent kidney function and no complications.

Beyond the Signature: Informed Consent from a Legal Perspective and Its Implications for Plastic Surgery.

SUMMARY: Informed consent is the principal tool that bridges the gap between clinical practice and our society's ethical ideals. The intricacies of informed consent, however, are frequently misunderstood, and its effective implementation can be challenging in practice. The continuous stream of innovations, wide array of procedures, and other characteristics inherent to the practice of plastic surgery compound the challenges of implementing informed consent. Unfortunately, there remains a dearth of literature to provide a comprehensive overview of informed consent as it relates to plastic surgery. In this article, the authors highlight the history, legal components, and challenges of informed consent within plastic surgery and offer recommendations on how to approach them. A deeper understanding of informed consent helps enhance patient care, mitigates unnecessary malpractice risk, and leads to better physician-patient relationships.

Pediatric Kidney Donation and Transplantation in Kingdom of Saudi Arabia.

The evolution of pediatric kidney donation and transplantation in the Kingdom of Saudi Arabia underscores the transformative effects of strategic initiatives and institutional reforms aimed at fostering self-sufficiency and ethical stewardship in transplantation. The ascendance of the Saudi Center for Organ Transplantation as a regional hub for organ procurement and transplantation is a testament to Saudi Arabia's commitment to advancing health care delivery and promoting international collaboration in combating organ trafficking and commercialism. Moving forward, sustained investments in infrastructure, capacity building, and regulatory oversight will be paramount to addressing emerging challenges and consolidating Saudi Arabia's position as a global leader in transplantation. By prioritizing patient welfare, ethical principles, and operational excellence, Saudi Arabia is poised to shape the future trajectory of pediatric kidney transplantation and usher in a new era of health care innovation and equity within the region and beyond.

An unusual hernia postkidney transplantation led to intermittent ureteric obstruction.

A 53-year-old man underwent a living donor kidney transplantation in the right iliac fossa 25 years prior to presentation. He had been noting an inguinal bugle that became more prominent as the day progressed, and it regressed at night. Upon further investigations, an ultrasound of the allograft revealed moderate-to-severe hydronephrosis. A computed tomography scan revealed herniation of the bladder and part of the transplanted ureter within the supravesical/direct inguinal space. Lichtenstein-like fashion of repair was performed, and the patient continues to enjoy satisfactory graft function with no recurrence. The case illustrates a rare hernia as a late complication of the kidney transplant incision leading to ureteric obstruction and a successful attempt at operative repair.

Effectiveness and Safety of Dupuytren Contracture Treatments: A Systematic Review and Meta-Analysis Using the GRADE Approach.

BACKGROUND: There is currently no consensus on the optimal treatment for Dupuytren contracture. Prior meta-analyses have been limited by suboptimal data synthesis methodologies. We conducted an updated evidence review comparing the effectiveness and safety of percutaneous needle fasciotomy (PNF), collagenase clostridium histolyticum (CCH), and limited fasciectomy (LF) using the GRADE approach. METHODS: CENTRAL, MEDLINE, and Embase were searched for randomized controlled trials comparing outcomes following PNF, CCH, and LF for Dupuytren contracture treatment. Outcomes of interest included residual contracture, recurrence rate, hand function, pain, global satisfaction, and adverse events. Time points included 3-months, 1-year, and 2-3 years. RESULTS: Seventeen publications (1,010 patients) were included. High to moderate certainty evidence showed no clinically important difference in long-term contracture reduction (PNF vs. LF (mean difference (MD): 7.6°; 95% CI: 1.8°-13.4°), CCH vs. LF (MD: 4.8°; 95% CI: -1.3°-10.9°)). Moderate certainty evidence indicated that LF provides the lowest risk of long-term recurrence (PNF vs. LF (relative risk (RR): 12.3; 95% CI: 1.6-92.4), CCH vs. LF (RR: 9.5; 95% CI 1.2-73.4)), LF has a higher risk of serious adverse events than PNF (RR: 0.5; 95% CI 0.3-0.9), and CCH has a higher risk of overall adverse events than PNF (RR: 4.8; 95% CI 2.9-7.0). CONCLUSIONS: CCH, PNF, and LF are equally effective in long-term contracture reduction. However, LF yields more durable results at a higher risk of rare but serious adverse events. Current evidence suggests the use of PNF over CCH. However, ultimate treatment decisions should be tailored to individual patient preferences.

Satisfaction and wellbeing of general surgery trainees in the Saudi Arabian residency educational environment: A mixed-methods study.

Background: Surgical residency training is prominently demanding and stressful. This can affect the residents' wellbeing, work-life balance and increase the rates of burnout. We aimed to assess rates of satisfaction and burn-out among GS residents in the national training programs and provide a subsequent in-depth analysis of the potential reasons. Method: A sequential explanatory mixed-methods study was conducted using an online survey and virtual interviews. The validated abbreviated Maslach Burnout Inventory (aMBI) was used to assess burnout while satisfaction was assessed via 5-points Likert scale. Results: After excluding incomplete responses from the total 74 received, 53 were analyzed. The average participant age was 27.4 ± 2 years, with females comprising 52 % of the sample. Junior residents made up 58.5 %, and nearly half -45 %- considered quitting GS training. Moderate to high burnout rates were noted on each aMBI subscale, ranging from 41.7 % to 62.5 %. The majority of residents expressed dissatisfaction with the level of research engagement (81.1 %), supervision, and mentorship. However, operative exposure was a source of satisfaction. Dissatisfaction rates with intra-operative learning, academia, teaching, and clinical exposure were 62.3 %, 52.8 %, 50.9 %, and 35.8 %, respectively. Interviews revealed surgical case flow and a friendly work environment as major satisfaction sources. Conversely, lack of academic supervision and suboptimal hands-on training were major dissatisfaction sources. Conclusion: Dissatisfaction and burn-out is prevalent among national GS training programs. Sub-optimal educational delivery and low-quality hands-on operative exposure -rather than lack of exposure to cases- seem to be the culprit.