Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Traumatic Brain Injury in Older Adults: Characteristics, Outcomes, and Considerations. Results From the American Association for the Surgery of Trauma Geriatric Traumatic Brain Injury (GERI-TBI) Multicenter Trial.

OBJECTIVES: Describe the epidemiology of a large cohort of older adults with isolated traumatic brain injury (TBI) and identify predictors of mortality, palliative interventions, and discharge to preinjury residence in those presenting with moderate/severe TBI. DESIGN: Prospective observational study of geriatric patients with TBI enrolled across 45 trauma centers. SETTING AND PARTICIPANTS: Inclusion criteria were age ≥40 years, and computed tomography (CT)-verified TBI. Exclusion criteria were any other body region abbreviated injury scale score >2 and presentation at enrolling center >24 hours after injury. METHODS: The analysis was restricted to individuals aged ≥65 and stratified into 3 age groups: young-old (65-74), middle-old (75-84), and oldest-old (≥85). Demographic, clinical, and injury data were collected. Predictors of mortality, palliative interventions, and discharge to preinjury residence in the moderate/severe TBI group were identified using Classification and Regression Tree and Generalized Linear Mixed Models. RESULTS: Of the 3081 subjects enrolled in the study, 2028 were ≥65 years old. Overall, 339 (16.7%) presented with a moderate/severe TBI and experienced a 64% mortality rate. A Glasgow Coma Scale (GCS) score <9 was the main predictor of mortality, CT worsening (odds ratio [OR] = 1.7, P < .04), cerebral edema (OR = 2.4, P < .04), GCS <9, and age ≥75 (OR = 2.1, P = .007) were predictors for palliative interventions, and an injury severity score ≤24 (OR = 0.087, P = .002) was associated with increased likelihood of discharge to preinjury residence in the moderate/severe TBI group. CONCLUSION AND IMPLICATIONS: In this prospective study of a large cohort of older adults with isolated TBI, comparisons across the older age groups with moderate/severe TBI revealed that survival and favorable discharge disposition were influenced more by severity of injury rather than age itself. Indicating that chronological age alone maybe insufficient to accurately predict outcomes, and increased representation of older adults in TBI research to develop better diagnostic and prognostic tools is warranted.

The Geriatric Nutritional Risk Index as a predictor of complications in geriatric trauma patients.

BACKGROUND: Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients. METHODS: This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI <82), moderate risk (GNRI 82-91), low risk (GNRI 92-98), and no risk (GNRI >98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes. RESULTS: A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home. CONCLUSIONS: Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Transforming a neural circuit to function without oxygen and glucose delivery.

Disruptions in the delivery of oxygen and glucose impair the function of neural circuits, with lethal consequences commonly observed in stroke and cardiac arrest. Intense focus has been placed on understanding how to overcome neuronal failure during energy stress. Important insights into neuroprotective strategies have come from studies of evolutionary adaptations for survival in hypoxic environments, such as those seen in turtles, naked mole-rats, and several other animals1. Amphibians are not usually numbered among 'champion' hypoxia-tolerant vertebrates, yet here we demonstrate a massive increase in the capacity of a neural circuit to produce activity following oxygen and glucose deprivation in adult bullfrogs. Rhythmic output from a brainstem circuit failed following minutes of severe hypoxia and simulated ischemia; however, after hibernation this network produced patterned activity for ∼3.5 hours during severe hypoxia and ∼2 hours in ischemia. This remarkable improvement was supported by a switch to brain glycogen to fuel anaerobic glycolysis, a pathway thought to support neuronal homeostasis for only a few minutes during ischemia2. These results reveal that circuit activity can exhibit dramatic metabolic plasticity that minimizes the need for ATP synthesis, and these findings represent the greatest range in hypoxia tolerance within a vertebrate neural network. Uncovering the rules that allow the brain to flexibly run only on endogenous fuel reserves will reveal new insights into brain energetics, circuit evolution, and neuroprotection.

Age-related Opioid Exposure in Trauma: A Secondary Analysis of the Multimodal Analgesia Strategies for Trauma (MAST) Randomized Trial.

OBJECTIVE: Evaluate the effect of age on opioid consumption after traumatic injury. SUMMARY BACKGROUND DATA: Older trauma patients receive fewer opioids due to decreased metabolism and increased complications, but adequacy of pain control is unknown. We hypothesized that older trauma patients require fewer opioids to achieve adequate pain control. METHODS: A secondary analysis of the multimodal analgesia strategies for trauma Trial evaluating the effectiveness of 2 multimodal pain regimens in 1561 trauma patients aged 16 to 96 was performed. Older patients (≥55 years) were compared to younger patients. Median daily oral morphine milligram equivalents (MME) consumption, average numeric rating scale pain scores, complications, and death were assessed. Multivariable analyses were performed. RESULTS: Older patients (n = 562) had a median age of 68 years (interquartile range 61-78) compared to 33 (24-43) in younger patients. Older patients had lower injury severity scores (13 [9-20] vs 14 [9-22], P = 0.004), lower average pain scores (numeric rating scale 3 [1-4] vs 4 [2-5], P < 0.001), and consumed fewer MME/day (22 [10-45] vs 52 [28-78], P < 0.001). The multimodal analgesia strategies for trauma multi-modal pain regimen was effective at reducing opioid consumption at all ages. Additionally, on multivariable analysis including pain score adjustment, each decade age increase after 55 years was associated with a 23% reduction in MME/day consumed. CONCLUSIONS: Older trauma patients required fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control.

Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS: We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS: Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION: Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Making your geriatric and palliative programs a strength: TQIP guideline implementation and the VRC perspective.

BACKGROUND: Older patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program's best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification. METHODS: We discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions. RESULTS: We describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen. DISCUSSION: Specialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes.Level of evidence V.

Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial.

BACKGROUND: Although widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL. METHODS: Eligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed. RESULTS: Of 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses. CONCLUSION: The findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma. LEVEL OF EVIDENCE: Level II.

Impact of Opioid-Minimizing Pain Protocols After Burn Injury.

In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre-group (from January 1, 2018 to July 31, 2019) and Post-group (from January 1, 2020 to June 30, 2020) from before and after the implementation of the protocols (from August 1, 2019 to December 31, 2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MMEs). Secondary outcomes included MMEs/day, pain domain-specific MMEs, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon rank-sum and chi-square tests. Treatment effects were estimated using Bayesian generalized linear models. There were no differences in demographics or burn characteristics between the Pre-group (n = 495) and Post-group (n = 174). The Post-group had significantly lower total MMEs (Post-group 110 MMEs [32, 325] vs Pre-group 230 [60, 840], P < .001), MMEs/day (Post-group 33 MMEs/day [15, 54] vs Pre-group 52 [27, 80], P < .001), and domain-specific total MMEs. No difference in average normalized pain scores was seen. Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.

Navigating the Infinite Number of Educational Resources: The Development of a Publicly Available Surgical Educational Digital Resource Library.

OBJECTIVE: There has been an explosion of digital resources available for general surgical education and board preparation. This makes it difficult for a new learner, regardless of their training level, to determine which resources best fit their needs. The uncertainty surrounding resource selection due to the large number of options causes stress, anxiety, and inefficiency for surgical learners. Our objective was to develop a digital surgical educational resource library to assist with selection. DESIGN: A needs assessment via multi-center focus groups encompassing all levels of learners from various subspecialties and training levels (medical students, trainees, junior surgeons, and senior surgeons) was performed to determine what information is desired in a surgical resource library. We conducted follow-up interviews and surveys to learn which resources were most commonly used for studying throughout training. SETTING: Multi-institutional RESULTS: The initial needs assessment detailed requests for an expansive array of surgical resources characterized by media type and price. We identified 104 resources that met these criteria. There were 33 resources used by medical students, 37 by residents, 16 used specifically for surgical boards preparation, and 25 by attending surgeons. These resources were composed of textbooks, review books, question banks, audio resources, video resources, and review courses. The prices of the resources ranged from free to greater than 400 dollars. CONCLUSIONS: A digital resource library should be broad and must address needs that change along a learner's career. Changes and improvements are required not only to meet the changing needs of the learners, but also to ensure the library remains current with the ever-growing number of resources. We plan to incorporate reviews of the resources from those surveyed to help visitors of the online library determine which resources may best suit their needs. Development of a digital resource library may assist learners by helping them easily identify what is available and has been peer reviewed allowing them to determine what best meets their educational needs.

When falls become fatal-Clinical care sequence.

OBJECTIVES: This study encompassed fall-related deaths, including those who died prior to medical care, that were admitted to multiple healthcare institutions, regardless of whether they died at home, in long-term care, or in hospice. The common element was that all deaths resulted directly or indirectly from injuries sustained during a fall, regardless of the temporal relationship. This comprehensive approach provides an unusual illustration of the clinical sequence of fall-related deaths. Understanding this pathway lays the groundwork for identification of gaps in healthcare needs. DESIGN: This is a retrospective study of 2014 fall-related deaths recorded by one medical examiner's office (n = 511) within a larger dataset of all trauma related deaths (n = 1848). Decedent demographic characteristics and fall-related variables associated with the deaths were coded and described. RESULTS: Of those falling, 483 (94.5%) were from heights less than 10 feet and 394 (77.1%) were aged 65+. The largest proportion of deaths (n = 267, 52.3%) occurred post-discharge from an acute care setting. Of those who had a documented prior fall, 216 (42.3%) had a history of one fall while 31 (6.1%) had ≥2 falls prior to their fatal incident. For the 267 post-acute care deaths, 440 healthcare admissions were involved in their care. Of 267 deaths occurring post-acute care, 129 (48.3%) were readmitted within 30 days. Preventability, defined as opportunities for improvement in care that may have influenced the outcome, was assessed. Of the 1848 trauma deaths, 511 (27.7%) were due to falls of which 361 (70.6%) were determined to be preventable or potentially preventable. CONCLUSION: Our data show that readmissions and repeated falls are frequent events in the clinical sequence of fall fatalities. Efforts to prevent fall-related readmissions should be a top priority for improving fall outcomes and increasing the quality of life among those at risk of falling.

High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury.

CONTEXT/OBJECTIVE: Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN: Cohort study. SETTING: Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS: Adult Acute Cervical SCI Patients, 2011-2018. INTERVENTIONS: HVtV. OUTCOME MEASURES: VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS: Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55-2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS: While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.

Mission-Based Filters in the Electronic Residency Application Service: Saving Time and Promoting Diversity.

BACKGROUND: Holistic review promotes diversity, but widespread implementation remains limited. OBJECTIVE: We aimed to develop a practical approach to incorporate holistic review principles in screening applicants in the Electronic Residency Application Service (ERAS) and to assess the impact on diversity. METHODS: Three residency programs (internal medicine [IM], pediatrics, and surgery) at McGovern Medical School developed filters to identify applicants with experiences/attributes aligned with the institutional mission. These filters were retroactively applied to each program's 2019-2020 applicant pool using built-in ERAS capabilities to group applicants by user-defined features. We compared the demographics of applicants reviewed during the cycle with those identified retrospectively through experiences/attributes filters. RESULTS: The IM, pediatrics, and surgery programs received 3527, 1341, and 1313 applications, respectively, in 2019-2020. Retrospective use of experiences/attributes filters, without scores, narrowed the IM applicant pool for review to 1301 compared to 1323 applicants reviewed during actual recruitment, while the pediatrics filters identified 514 applicants compared to 384 at baseline. The surgery filters resulted in 582 applicants, but data were missing for baseline comparison. Compared to the baseline screening approach utilizing scores, mission-based filters increased the proportions of underrepresented in medicine applicants selected for review in IM (54.8% [95% CI 52.1-57.5] vs 22.7% [20.4-24.9], P < .0001) and pediatrics (63.2% [95% CI 59.1-67.4] vs 25.3% [20.9-29.6], P < .0001). CONCLUSIONS: Program directors can leverage existing ERAS features to conduct application screening in alignment with holistic review principles. Widespread implementation could have important repercussions for enhancing physician workforce diversity.

Neuromodulation or energy failure? Metabolic limitations silence network output in the hypoxic amphibian brainstem.

Hypoxia tolerance in the vertebrate brain often involves chemical modulators that arrest neuronal activity to conserve energy. However, in intact networks, it can be difficult to determine whether hypoxia triggers modulators to stop activity in a protective manner or whether activity stops because rates of ATP synthesis are insufficient to support network function. Here, we assessed the extent to which neuromodulation or metabolic limitations arrest activity in the respiratory network of bullfrogs-a circuit that survives moderate periods of oxygen deprivation, presumably, by activating an inhibitory noradrenergic pathway. We confirmed that hypoxia and norepinephrine (NE) reduce network output, consistent with the view that hypoxia may cause the release of NE to inhibit activity. However, these responses differed qualitatively; hypoxia, but not NE, elicited a large motor burst and silenced the network. The stereotyped response to hypoxia persisted in the presence of both NE and an adrenergic receptor blocker that eliminates sensitivity to NE, indicating that noradrenergic signaling does not cause the arrest. Pharmacological inhibition of glycolysis and mitochondrial respiration recapitulated all features of hypoxia on network activity, implying that reduced ATP synthesis underlies the effects of hypoxia. Finally, activating modulatory mechanisms that dampen neuronal excitability when ATP levels fall, KATP channels and AMP-dependent protein kinase, did not resemble the hypoxic response. These results suggest that energy failure-rather than inhibitory modulation-silences the respiratory network during hypoxia and emphasize the need to account for metabolic limitations before concluding that modulators arrest activity as an adaptation for energy conservation in the nervous system.