A Call to Action to Train Underrepresented Minorities in Surgical Subspecialties and Fellowships.

BACKGROUND: With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time. STUDY DESIGN: The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American. RESULTS: From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001). CONCLUSIONS: Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway.

Effects of COVID-19 on Surgical Delays in Patients with Breast Cancer in NYC Public Hospitals: A Multicenter Study.

BACKGROUND: Increased time to surgery (TTS) is associated with decreased survival in patients with breast cancer. In early 2020, elective surgeries were canceled to preserve resources for patients with coronavirus disease 2019 (COVID-19). This study attempts to measure the effect of mandated operating room shutdowns on TTS in patients with breast cancer. PATIENTS AND METHODS: This multicenter retrospective study compares 51 patients diagnosed with breast cancer at four public hospitals from January to June 2020 with 353 patients diagnosed from January 2017 to June 2018. Demographics, tumor characteristics, treatment regimens, and TTS for patients were statistically compared using parametric, nonparametric, and Cox proportional hazards regression modeling. RESULTS: Across all centers, there was a non-statistically significant increase in median TTS from 59 days in the pre-COVID period to 65 days during COVID (p = 0.9). There was, however, meaningful variation across centers. At center A, the median TTS decreased from 57 to 51 days, center C's TTS decreased from 83 to 64 days, and in center D, TTS increased from 42 to 129 days. In a multivariable Cox proportional hazards model for the pre-COVID versus COVID period effect on TTS, center was an important confounding variable, with notable differences for centers C and D compared with the referent category of center A (p = 0.04, p = 0.006). CONCLUSION: Data suggest that, while mandated operating room shutdowns did not result in an overall statistically significant delay in TTS, there were important differences between centers, indicating that, even in a unified multicenter public hospital system, COVID-19 may have resulted in delayed and potentially disparate care.

Disparity in Transport of Critically Injured Patients to Trauma Centers: Analysis of the National Emergency Medical Services Information System (NEMSIS).

BACKGROUND: Patient morbidity and mortality decrease when injured patients meeting CDC Field Triage Criteria (FTC) are transported by emergency medical services (EMS) directly to designated trauma centers (TCs). This study aimed to identify potential disparities in the transport of critically injured patients to TCs by EMS. STUDY DESIGN: We identified all patients in the National EMS Information System (NEMSIS) database in the National Association of EMS State Officials East region from January 1, 2018, to December 31, 2019, with a final prehospital acuity of critical or emergent by EMS. The cohort was stratified into patients transported to TCs or non-TCs. Analyses consisted of descriptive epidemiology, comparisons, and multivariable logistic regression analysis to measure the association of demographic features, vital signs, and CDC FTC designation by EMS with transport to a TC. RESULTS: A total of 670,264 patients were identified as sustaining an injury, of which 94,250 (14%) were critically injured. Of those 94,250 critically injured, 56.0% (52,747) were transported to TCs. Among all critically injured women (n = 41,522), 50.4% were transported to TCs compared with 60.4% of critically injured men (n = 52,728, p < 0.001). In a multivariable logistic regression model, critically injured women were 19% less likely to be taken to a TC compared with critically injured men (OR 0.81, 95% CI 0.71-0.93, p = 0.003). CONCLUSIONS: Critically injured female patients are less likely to be transported to TCs when compared with their male counterparts. Performance improvement processes that assess EMS compliance with field triage guidelines should explicitly evaluate for sex-based disparities. Further studies are warranted.

Tumor volume improves preoperative differentiation of prolactinomas and nonfunctioning pituitary adenomas.

PURPOSE: Both prolactinomas and nonfunctioning adenomas (NFAs) can present with hyperprolactinemia. Distinguishing them is critical because prolactinomas are effectively managed with dopamine agonists, whereas compressive NFAs are treated surgically. Current guidelines rely only on serum prolactin (PRL) levels, which are neither sensitive nor specific enough. Recent studies suggest that accounting for tumor volume may improve diagnosis. The objective of this study is to investigate the diagnostic utility of PRL, tumor volume, and imaging features in differentiating prolactinoma and NFA. METHODS: Adult patients with pathologically confirmed prolactinoma (n = 21) or NFA with hyperprolactinemia (n = 58) between 2013 and 2020 were retrospectively identified. Diagnostic performance of clinical and imaging variables was analyzed using receiver-operating characteristic curves to calculate area under the curve (AUC). RESULTS: Tumor volume and PRL positively correlated for prolactinoma (r = 0.4839, p = 0.0263) but not for NFA (r = 0.0421, p = 0.7536). PRL distinguished prolactinomas from NFAs with an AUC of 0.8892 (p < 0.0001) and optimal cut-off value of 62.45 ng/ml, yielding a sensitivity of 85.71% and specificity of 94.83%. The ratio of PRL to tumor volume had an AUC of 0.9647 (p < 0.0001) and optimal cut-off value of 21.62 (ng/ml)/cm3 with sensitivity of 100% and specificity of 82.76%. Binary logistic regression found that PRL was a significant positive predictor of prolactinoma diagnosis, whereas tumor volume, presence of cavernous sinus invasion, and T2 hyperintensity were significant negative predictors. The regression model had an AUC of 0.9915 (p < 0.0001). CONCLUSIONS: Consideration of tumor volume improves differentiation between prolactinomas and NFAs, which in turn leads to effective management.

The Devastating Impact of the COVID-19 Pandemic on Breast Cancer Care Among Medically Underserved Populations at Two New York City Public Hospitals.

The COVID-19 pandemic has stretched hospitals to their capacities and has forced them to restructure and divert resources to accommodate the influx of critically ill patients. Surgical specialties are particularly vulnerable to restructuring given the need for highly trained personnel with intensive care unit (ICU) experience and procedural skills and need for ventilators and spaces that can function as ICUs. The diversion of hospital resources and redeployment of staff to the care of COVID patients has led to unintended consequences, including delays in care for patients with oncologic diagnoses, such as breast cancer. These unintended consequences are illustrated by the COVID-19 experiences of 2 New York City public hospitals: Bellevue Hospital and Elmhurst Hospital. The Breast Services of both hospitals treat the city's vulnerable, medically underserved breast cancer patients. Despite similar patient populations, Bellevue and Elmhurst had divergent COVID-19 experiences. With a larger surge capacity and an affiliation with New York University, the Breast Service at Bellevue Hospital was able to continue to offer essential breast operations, albeit at reduced volumes, whereas the Breast Service at Elmhurst Hospital was completely shut down. These experiences serve as a harbinger of the continually widening health care disparities and force hospital systems and policymakers to critically examine the impact of the COVID-19 pandemic on underserved patient populations that receive care at smaller public hospitals.