Preoperative Advance Care Planning for Older Adults Undergoing Major Abdominal Surgery.

BACKGROUND: Advance care planning (ACP) is recommended for older patients undergoing surgery. ACP consists of creating advance directives (ADs), identifying surrogate decision makers (SDMs), and documenting goals of care. We identified factors associated with documentation of preoperative ACP to identify opportunities to optimize ACP for older surgical patients. METHODS: This was a retrospective study of surgical patients ≥70 years old who underwent elective, high-risk abdominal procedures between 01/2015-08/2019. Clinical data were obtained from our institution's National Surgical Quality Improvement Project database. ACP metrics were extracted from the electronic medical record. We analyzed the data to identify patient factors associated with ACP metrics. We also analyzed whether ACP was more frequent for patients who experienced postoperative complications or death. RESULTS: 267/1,651 patients were included. 97 patients (36%) had an AD available on the day of surgery, 57 (21%) had an SDM identified, and 31 (12%) had a documented goals of care conversation. On multivariable analysis, older age and white race were associated with an increased likelihood of having an AD available on the day of surgery. Women were 1.7 times more likely to have an SDM (p = 0.02). No patient or surgeon factors were significantly associated with goals of care documentation. ACP was not performed more frequently in patients who experienced postoperative complications or death. CONCLUSION: In this series, ACP was not routinely documented for older patients undergoing major surgery. ACP was not more frequent in patients who experienced complications or death, demonstrating the importance of universal preoperative ACP in older patients.

The effects of cannabidiol and analgesic expectancies on experimental pain reactivity in healthy adults: A balanced placebo design trial.

Despite its frequent use for pain relief, no experimental pain research has tested the analgesic effects of cannabidiol (CBD) in humans. The goal of this study was to experimentally test the effects of CBD and expectancies for receiving CBD on human pain reactivity. Using a crossover, 2 × 2 factorial balanced placebo design, drug administration (given inactive substance or given active CBD) and verbal instruction sets (told inactive substance or told active CBD) were experimentally manipulated. Fifteen healthy adults each completed four separate experimental sessions. Participants were randomly assigned to different counterbalanced manipulation conditions at each session: control (told inactive-given inactive); expectancy (told active CBD-given inactive); drug (told inactive-given active CBD); and expectancy + drug (told active CBD-given active CBD). Primary outcomes were pain threshold, tolerance, intensity, unpleasantness, conditioned pain modulation (CPM), and offset analgesia (OA). There was a significant main effect of instructions on OA, such that the OA response was significantly larger when participants were told that they received CBD, regardless of drug content. Pain unpleasantness was significantly reduced in the drug, expectancy, and expectancy + drug conditions, relative to the control condition. The drug and expectancy conditions separately improved CPM, whereas the expectancy + drug and control conditions produced the lowest CPM change scores. We did not detect significant effects for pain threshold, tolerance, or intensity. Our results indicated that separate pain outcomes can be differentially affected by CBD and/or expectancies for receiving CBD. Future investigations of the psychological and pharmacological mechanisms underlying CBD analgesia are warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Development and validation of the Body Compassion Questionnaire.

BACKGROUND: The associations between compassion, self-compassion, and body image are well established. However, there is not yet a compassion-informed measure of body compassion that can be applied to any aspect of one's body. METHOD: Items for The Body Compassion Questionnaire (BCQ) were derived from an earlier expressive writing study on self-compassion in body image. In study 1, the BCQ was completed by 728 men and women; with factor analysis, Rasch analysis, content and concurrent validation and reliability assessed. Study 2 compared BCQ scores with investigator-based ratings of spontaneous expressions of body compassion through writing in female undergraduates as well as an existing measure of body compassion. Study 3 examined the associations between BCQ scores, and the emotions expressed in a structured body image writing task. It also examined the relative predictive ability of the BCQ versus self-compassion in predicting eating pathology. RESULTS: A bi-factor structure was identified, with an overall BCQ score and three subscales: body kindness, common humanity, and motivated action. The BCQ and its subscales had good validity and reliability and Rasch analysis showed the item fit was invariant across a range of demographic characteristics. Spontaneous expressions of body compassion showed positive associations with body kindness. Overall BCQ scores and body kindness were also inversely related to negative emotions expressed in relation to body image. The BCQ was a better predictor of eating disorder symptoms than was self-compassion. CONCLUSIONS: The BCQ is the first measure of body compassion that is aligned with theoretical aspects of self-compassion, and which includes aspects of both the first and second psychologies of compassion. It also highlights its potential use as a process measure of body compassion in models of eating disorder symptomology, mood and wellbeing as well as an outcome measure for compassion-based interventions in eating disorders and body image.

Behind the Mask: An Exploratory Assessment of Female Surgeons' Experiences of Gender Bias.

Though overt sexism is decreasing, women now experience subtle, often unconscious, gender bias as microaggressions. The authors sought to explore the prevalence and impact of the sexist microaggressions female surgeons experience, using a sequential exploratory mixed methods approach (January 2018-April 2018), to identify opportunities for education and prevention. First, all resident, fellow, and attending female surgeons at the University of New Mexico Health Sciences Center (UNM HSC) were invited to participate in focus groups conducted by experienced moderators using a semistructured interview guide based on the 7 Sexist Microaggressions Experiences and Stress Scale (Sexist MESS) domains. Qualitative analysis was performed using line-by-line manual coding to identify themes aligned with the Sexist MESS domains as well as other gender bias experiences of female surgeons. Next, a survey was sent to all resident, fellow, and attending female surgeons at the UNM HSC, which included the Sexist MESS questionnaire and questions related to surgeon-specific experiences of gender bias that the authors developed based on major thematic categories from the focus groups.Four focus groups of 23 female surgeons were conducted, revealing 4 themes: exclusion, increased effort, adaptation, and resilience to workplace slights. The survey response rate was 64% (65/101 surgeons). Across Sexist MESS domains, the frequency and severity of microaggressions was higher for trainees than attendings. The variables of non-White race/ethnicity, having children under 18, and fellowship training generally did not demonstrate statistical significance. This exploratory study adds to the growing body of evidence that gender bias in surgery continues and frequently manifests as microaggressions. Trainees reported the highest rates and severity of microaggressions and bias experiences. Further research should investigate how to address microaggressions, the experiences of male surgeons, the perspectives of medical students and groups who were reported as often perpetuating gender bias, and the efficacy of possible interventions.

Recurrence patterns in patients with Stage II melanoma: The evolving role of routine imaging for surveillance.

BACKGROUND AND OBJECTIVES: The relatively recent availability of effective systemic therapies for metastatic melanoma necessitates reconsideration of current surveillance patterns. Evidence supporting surveillance guidelines for resected Stage II melanoma is lacking. Prior reports note routine imaging detects only 21% of recurrent disease. This study aims to define recurrence patterns for Stage II melanoma to inform future surveillance guidelines. METHODS: This is a retrospective study of patients with Stage II melanoma. We analyzed risk factors for recurrence and methods of recurrence detection. We also assessed survival. Yearly hazards of recurrence were visualized. RESULTS: With a median follow-up of 4.9 years, 158 per 580 patients (27.2%) recurred. Overall, most recurrences were patient-detected (60.7%) or imaging-detected (27.3%). Routine imaging was important in detecting recurrence in patients with distant recurrences (adjusted rate 43.1% vs. 9.4% for local/in-transit; p = .04) and with Stage IIC melanoma (42.5% vs. 18.5% for IIA; p = .01). Male patients also self-detected recurrent disease less than females (52.1% vs. 76.8%; p < .01). CONCLUSIONS: Routine imaging surveillance played a larger role in detecting recurrent disease for select groups in this cohort than noted in prior studies. In an era of effective systemic therapy, routine imaging should be considered for detection of asymptomatic relapse for select, high-risk patient groups.

Gender Bias Experiences of Female Surgical Trainees.

OBJECTIVE: Medical schools now average approximately 50% female students, yet a disproportionate number of women continue to choose nonsurgical over surgical specialties. Once in training, studies indicate that pervasive gender stereotypes, sexism and harassment negatively affect female surgeons. The aim of this study is to describe female surgeons' experiences with gender bias and microaggressions in the workplace during residency and fellowship training, and understand if differences exist in the experiences of trainees in male-dominant vs female-dominant surgical specialties. DESIGN: A mixed methods approach was used to explore the experiences of female surgical trainees. Participants were recruited from all surgical disciplines at an academic center. Initially, focus groups were used to explore themes that trainees face related to gender bias. A trained moderator conducted all focus groups, which were audio recorded and transcribed. Qualitative analysis of de-identified transcripts was performed to identify emerging themes. We then created an online survey using the validated 44-question Sexist Microaggression Experiences and Stress Scale to assess frequency and psychologic impact of these events with additional questions developed from the focus groups. The survey was sent to all female residents and fellows at one academic institution. SETTING: University of New Mexico Hospital, a tertiary care academic medical center. PARTICIPANTS: Fifteen female surgical trainees participated in focus groups. Thirty-three female surgical trainees participated in the online survey. RESULTS: Two focus groups including 15 female trainees were conducted, revealing 4 themes: Exclusion, Adaptation, Increased effort, and Development of Resilience Strategies. All participants had experienced gender bias or discrimination during medical school or surgical training. The quantitative survey had a 66% response rate (33/50 female trainees). Significant differences were found in the experience of female trainees in male-dominant vs female-dominant specialties, with those in male-dominant fields often reporting more frequent, severe, and stressful microaggression experiences. When describing how gender bias would affect their future in medicine, trainees in male-dominant specialties were more likely to report that due to gender bias, they "may leave medicine/retire early" (33% vs 6%, p = 0.040) and that they "would not recommend my profession to trainees or family members" (40% vs 6%, p = 0.015)." CONCLUSIONS: Female surgical trainees continue to experience gender bias. A culture of sexism leads to physical and social adaptations to fit into the role of surgeon. Participants expressed significant effort to sustain this level of adaptation, leading to fatigue and creation of resilience mechanisms. The environment in which a trainee operates (male-dominant vs female-dominant) significantly impacts their experience. Those experiencing more bias were less likely to recommend their specialty and reported plans to leave medicine earlier. Culture change across institutions and system-level interventions are necessary to create meaningful and sustainable change that improves the experience of female surgical trainees.

Pattern recognition receptor gene expression in ischemia-induced flap revascularization.

BACKGROUND: The innate immune system is the major contributor to acute inflammation induced by microbial infection or tissue damage. Germline-encoded pattern recognition receptors (PRRs) are responsible for sensing the presence of micro-organisms and endogenous molecules released from damaged cells. We performed microarray analyses on ischemic wound tissue to investigate the temporal relationship between PRR gene expression, wound perfusion, and flap revascularization. METHODS: A cranial-based, peninsular-shaped myocutaneous flap was surgically created on the dorsum of C57BL6 mice (n = 25 total; n = 20 with flap). Laser speckle contrast imaging was utilized to study the pattern of flap ischemia and return of functional revascularization. Flap microvascular density was determined by image analysis of CD-31-immunostained sections. Total RNA was isolated from homogenized flap tissue and was converted to cDNA (RT), which was hybridized to a microarray of pathway-focused genes. Microarray results were validated with quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR). RESULTS: Laser speckle contrast imaging predicted the spatial and temporal pattern of ischemia and functional revascularization. Histologic analysis demonstrated early leukocyte infiltration and later engraftment, resulting in flap revascularization by new blood vessel growth from the recipient bed and dilatation of preexisting proximal flap vasculature. qRT-PCR demonstrated significant early gene expression of select PRRs, cytokines, chemokines, and growth factors, peaking by 48 hours, and returning toward baseline but remaining elevated at 10 days. CONCLUSION: Surgical and ischemic tissue injury resulted in the early gene expression of select PRRs, which may bind with endogenous molecules released from ischemic or necrotic cells, leading to transcription of genes involved in wound inflammation and angiogenesis.