Implementation of a Holistic Review Process of US Allopathic Medical Students Eliminates Non-Comparable Metrics and Bias in General Surgery Residency Interview Invitations.

OBJECTIVE: Use of traditional scoring metrics for residency recruitment creates racial and gender bias. In addition, widespread use of pass/fail grading has led to noncomparable data. To adjust to these challenges, we developed a holistic review (HR) rubric for scoring residency applicants for interview selection. DESIGN: Single-center observational study comparing the proportion of underrepresented in medicine (URM) students and their United States Medical Licensing Exam (USMLE) scores who were invited for interview before (2015-2020) and after (2022) implementation of a holistic review process. SETTING: General surgery residency program at a tertiary academic center. PARTICIPANTS: US allopathic medical students applying for general surgery residency. RESULTS: After initial screening, a total of 1514 allopathic applicants were narrowed down to 586 (38.7%) for HR. A total of 52% were female and 17% identified as URM. Based on HR score, 20% (118/586) of applicants were invited for an interview. The median HR score was 11 (range 4-19). There was a fourfold higher coefficient of variation of HR scores (22.3; 95% CI 21.0-23.7) compared to USMLE scores (5.1; 95% Cl 4.8-5.3), resulting in greater spread and distinction among applicants. There were no significant differences in HR scores between genders (p = 0.60) or URM vs non-URM (p = 0.08). There were no significant differences in Step 1 (p = 0.60) and 2CK (p = 0.30) scores between those who were invited to interview or not. On multivariable analysis, USMLE scores (OR 1.01; 95% CI 0.98-1.03), URM status (OR 1.71 95% CI 0.98-2.92), and gender (OR 0.94, 95% CI 0.60-1.45) did not predict interview selection (all p > 0.05). There was a meaningful increase in the percentage of URM interviewed after HR implementation (12.9% vs 23.1%, p = 0.016). CONCLUSION: The holistic review process is feasible and eliminates the use of noncomparable metrics for surgical applicant interview invitations and increases the percentage of URM applicants invited to interview.

The use of ultrasound in establishing COVID-19 infection as part of a trauma evaluation.

PURPOSE: The use of lung ultrasound for diagnosis of COVID-19 has emerged during the pandemic as a beneficial diagnostic modality due to its rapid availability, bedside use, and lack of radiation. This study aimed to determine if routine ultrasound (US) imaging of the lungs of trauma patients with COVID-19 infections who undergo extended focused assessment with sonography for trauma (EFAST) correlates with computed tomography (CT) imaging and X-ray findings, as previously reported in other populations. METHODS: This was a prospective, observational feasibility study performed at two level 1 trauma centers. US, CT, and X-ray imaging were retrospectively reviewed by a surgical trainee and a board-certified radiologist to determine any correlation of imaging findings in patients with active COVID-19 infection. RESULTS: There were 53 patients with lung US images from EFAST available for evaluation and COVID-19 testing. The overall COVID-19 positivity rate was 7.5%. COVID-19 infection was accurately identified by one patient on US by the trainee, but there was a 15.1% false-positive rate for infection based on the radiologist examination. CONCLUSIONS: Evaluation of the lung during EFAST cannot be used in the trauma setting to identify patients with active COVID-19 infection or to stratify patients as high or low risk of infection. This is likely due to differences in lung imaging technique and the presence of concomitant thoracic injury.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION: Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture. METHODS: A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. RESULTS: Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. CONCLUSIONS: Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Disparities in Emergency Versus Elective Surgery: Comparing Measures of Neighborhood Social Vulnerability.

BACKGROUND: Several composite measures of neighborhood social vulnerability exist and are used in the health disparity literature. This study assesses the performance of the Social Vulnerability Index (SVI) compared with three similar measures used in the surgical literature: Area Deprivation Index (ADI), Community Needs Index (CNI), and Distressed Communities Index (DCI). There are advantages of the SVI over these other scales, and we hypothesize that it performs equivalently. METHODS: We identified all cholecystectomies at a single, urban, academic hospital over a 9-month period. Cases were considered emergency if the patient presented and underwent surgery during that admission. We geocoded patient's addresses and assigned estimated SVI, ADI, CNI, and DCI. Cutoffs for high versus low social vulnerability were generated using Youden's index, and the scales were compared using multivariable modeling. RESULTS: Overall, 366 patients met inclusion criteria, and the majority (n = 266, 73%) had surgery in the emergency setting. On multivariable modeling, patients with high social vulnerability were more likely to undergo emergency surgery compared with those with low social vulnerability in accordance with all four scales: SVI (OR 3.24, P < 0.001), ADI (OR 3.2, P < 0.001), CNI (OR 1.90, P = 0.04), and DCI (OR 2.01, P = 0.03). The scales all had comparable predictive value. CONCLUSIONS: The SVI performs similarly to other indices of neighborhood vulnerability in demonstrating disparities between emergency and elective surgery and is readily available and updated. Because the SVI has multiple subcategories in addition to the overall measure, it can be used to stratify by modifiable factors such as housing or transportation to inform interventions.

Cholecystectomy: Exploring the Interplay Between Access to Care and Emergent Presentation.

BACKGROUND: The burden of emergency general surgery leads to higher cost and less compensation to institutions; cholecystectomy accounts for >150,000 cases/y, the highest number of emergency general surgery cases that have a potentially elective course. We hypothesize that our cholecystectomy patient pool has unique characteristics informing health care access in our area. METHODS: We retrospectively identified cholecystectomy patients at our academic hospital over a 6-mo period from January to June of 2018 and classified them as emergent or elective. We excluded pregnant patients, patients aged <18 y, and patients who had undergone another major procedure concurrently. Patient demographics and clinical course were abstracted from the medical record. RESULTS: Two hundred and sixty-seven patients were included in the study, with most patients (n = 196, 73.4%) presenting emergently. We found no differences in age, sex, or BMI between the two groups. Emergent patients were more likely to be minorities, less likely to have insurance or a primary care physician, and 25% required an interpreter. Although a greater percentage of patients in the elective setting had chronic symptoms, most emergent patients also had duration of symptoms of months to years. After multivariable analysis, insurance status, lack of a primary care provider, and chronic duration of symptoms remained significant predictors of emergent presentation. CONCLUSIONS: Our findings indicate several targets for increasing access to elective surgical care. Most patients in the emergent group experienced chronic symptoms, indicating an opportunity to prevent emergency surgical treatment. This study provides local population characterization for improvements in access to care, which could lead to decreases in emergency gallbladder surgery.

It doesn't just happen to "Other" people - An exploration of occupation and education level of women who die from intimate partner violence.

INTRODUCTION: While age, sex, and race/ethnicity of victims of intimate partner violence (IPV) have been described, little has been examined regarding other characteristics. We aim to characterize occupation and education levels of female victims of IPV homicide. METHODS: We retrospectively reviewed the National Violent Death Reporting System from 2003 to 2015 for victims of IPV homicide. Occupation, industry, and education fields were examined to categorize victims according to the 2010 Standard Occupation Classification. RESULTS: 4931 female victims of IPV were included. When clustering by job type, no single group dominated. Most victims had completed at least high school, with approximately 20% having at least some college. CONCLUSION: Occupation and education level of women victims do not predict or protect against homicide in IPV, and these details are often omitted in data collection. This underscores the societal ubiquity of this public health crisis and argues for universal screening and better data collection, including in surgical populations.

Using the Social Vulnerability Index to Examine Local Disparities in Emergent and Elective Cholecystectomy.

BACKGROUND: The Social Vulnerability Index (SVI) is a composite scale formulated by the Centers for Disease Control and is geocoded as a percentile ranking at the census tract level. SVI is potentially applicable to assess risk and target populations that are likely to present emergently for disease that could have been treated electively and target local disparities. We applied the SVI to compare cholecystectomy patients presenting emergently versus electively. METHODS: We identified patients who had undergone cholecystectomy at our academic medical center over a 6-month period. We abstracted patient demographics, chronic symptom duration, and diagnosis from the medical record. Patient addresses were geocoded to identify their census tract of residence and estimated SVI. RESULTS: Two hundred and fifty five patients met inclusion criteria. Most patients (n = 185, 72.5%) had surgery in the emergent setting. Emergent patients lived in areas of greater social vulnerability compared with elective patients (median SVI 75th versus 64th percentile, P < 0.001). On multivariable analysis adjusting for chronicity of symptoms and patient proximity to the hospital, having high SVI (>70th percentile) was associated with higher odds of undergoing an emergent versus an elective procedure (OR 2.05, P = 0.04). CONCLUSIONS: The SVI has potential utility for examining health care disparities, performing comparably with a more complex model including individual risk factors. Because it is a composite measure geocoded at the census tract level for all communities in the United States, it has potential for targeting relatively discrete geographic areas for intervention. Being a geocoded measure also offers opportunity for linking with other data sets using geographic information systems.

Preventable death and interpersonal violence in the United States: Who can be saved?

BACKGROUND: Public health initiatives to reduce mortality from penetrating trauma have largely developed from patterns of injury observed in military casualties, with a focus on hemorrhage control and use of tourniquets. Recent efforts show that injury patterns differ between civilian mass casualty events and combat settings, and no studies characterize wounding patterns in all types of civilian homicide. We hypothesize that many homicide deaths are due to nonsurvivable injuries, and that an effective strategy to reduce mortality must focus on both primary prevention as well as improvement in trauma prehospital care. METHODS: We analyzed homicides from the National Violent Death Reporting System from 2012 to 2015. We excluded deaths due to poisoning, intentional neglect, or unknown weapon. Deaths were classified as "dead on scene" (DOS), "dead on arrival" (DOA), or "dead at or after hospital" (DAH) if the patient was admitted to a hospital. Injury patterns for penetrating weapons (firearms and sharp instruments) were further categorized. RESULTS: We included 18,051 homicides, the vast majority of which were due to firearms (n = 12,901 or 71.5%) or sharp instruments (n = 2,265 or 12.5%). The most common injury patterns included wounds to the chest or head, with isolated extremity injuries representing a minority of both firearms deaths (n = 397 of 12,901, 3.1%) and deaths from sharp instruments (n = 50 of 2,265, 2.2%). Furthermore, over half of all deaths occurred prehospital, with only 13.3% of victims admitted prior to death. CONCLUSION: The vast majority of deaths from interpersonal violence are due to firearm injuries. Few deaths appear to be related to extremity hemorrhage alone, and over half of all fatally injured died at the scene. Strategies to decrease mortality from interpersonal violence must go beyond treating injuries that have already occurred, and must address violence prevention directly. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Delayed Presentation of a Vertex Epidural Hematoma Following High-Voltage Electrical Injury to the Head.

We present the case of a man who suffered a high-voltage electrical injury followed by a delayed presentation of an epidural hematoma. CT of the brain demonstrated hyper dense material along the anterior and frontal region consistent with an epidural hematoma at the vertex. The patient underwent serial computed tomography scans of his brain which demonstrated stability of the hematoma and no operative intervention was required. This appears to be the first case report of such an injury.

Mammograms on-the-go-predictors of repeat visits to mobile mammography vans in St Louis, Missouri, USA: a case-control study.

OBJECTIVES: Among women, breast cancer is the most common non-cutaneous cancer and second most common cause of cancer-related death. The purpose of this study was to determine the extent to which women use mobile mammography vans for breast cancer screening and what factors are associated with repeat visits to these vans. DESIGN: A case-control study. Cases are women who had a repeat visit to the mammography van. (n=2134). PARTICIPANTS: Women who received a mammogram as part of Siteman Cancer Center's Breast Health Outreach Program responded to surveys and provided access to their clinical records (N=8450). Only visits from 2006 to 2014 to the mammography van were included. OUTCOME MEASURES: The main outcome is having a repeat visit to the mammography van. Among the participants, 25.3% (N=2134) had multiple visits to the mobile mammography van. Data were analysed using χ(2) tests, logistic regression and negative binomial regression. RESULTS: Women who were aged 50-65, uninsured, or African-American had higher odds of a repeat visit to the mobile mammography van compared with women who were aged 40-50, insured, or Caucasian (OR=1.135, 95% CI 1.013 to 1.271; OR=1.302, 95% CI 1.146 to 1.479; OR=1.281, 95% CI 1.125 to 1.457), respectively. However, the odds of having a repeat visit to the van were lower among women who reported a rural ZIP code or were unemployed compared with women who provided a suburban ZIP code or were employed (OR=0.503, 95% CI 0.411 to 0.616; OR=.868, 95% CI 0.774 to 0.972), respectively. CONCLUSION: This study has identified key characteristics of women who are either more or less likely to use mobile mammography vans as their primary source of medical care for breast cancer screening and have repeat visits.

Predictive factors and patterns of recurrence in patients with triple negative breast cancer.

BACKGROUND: We investigated the outcomes of patients with triple negative breast cancer ([TNBC] = estrogen receptor negative, progesterone receptor negative, and HER2 nonamplified). METHODS: We identified 414 patients with stage I-III TNBC treated between 1999 and 2008. Data included patient/tumor characteristics, surgical, systemic, and radiation treatment received, and breast cancer-specific survival. Data were compared using Chi square, Fisher exact test, and logistic regression. A p value <.05 was considered significant. RESULTS: The cohort included 414 patients (mean age 53.8 ± 12.5 years) with a mean follow-up of 68.2 ± 36.4 months. Of 414 patients, 304 (73.4 %) had no evidence of recurrence, while 110 (26.6 %) had recurrent disease, including 19 (17.3 %) with isolated locoregional recurrence, 70 (63.6 %) with isolated distant recurrence, and 21 (19.1 %) with both. Of 91 patients with distant recurrences, lung was most common (n = 38), followed by brain (n = 32), bone (n = 31), and liver (n = 29). Factors significantly associated with recurrence included increasing tumor size, positive nodal status, increasing stage, and type of chemotherapy (adjuvant vs neoadjuvant). After controlling for all potential confounders in multivariate stepwise regression, these same factors were also found to be independent predictors of recurrence. In the survival analysis, these same factors, in addition to receipt of radiation were found to be predictive of survival. CONCLUSIONS: Approximately 25 % of patients with TNBC experienced a locoregional and/or distant recurrence, resulting in greater than 75 % breast cancer-specific mortality for those who experienced a distant recurrence. The lack of targeted therapy for this aggressive breast cancer subtype likely contributed to this finding.

Impact of radiation therapy on survival in patients with triple-negative breast cancer.

Triple-negative breast cancer (TNBC) has a poorer prognosis compared with other sub-groups. In the current study, survival associated with locoregional treatment of females with TNBC was investigated. Specifically, 468 patients with stage I-III TNBC treated between 2002 and 2009 were identified. Data included patient and tumor characteristics, treatment received and survival. Data were compared using χ2 and Fisher's exact tests, as well as MANOVA. Kaplan-Meier curves were generated. The study cohort had a mean age of 54±13 years old with a mean follow-up period of 51±21 months. Of 468 patients, 249 (53%) underwent lumpectomy, 63 (14%) underwent simple mastectomy (SM) and 156 (33%) underwent modified radical mastectomy (MRM). Overall, 263 (56%) received adjuvant radiation, including 178/249 (71%) following lumpectomy, 13/63 (21%) following SM and 72/156 (46%) following MRM (P<0.0001). Following control for potential confounders in univariate tests, adjuvant radiation was associated with improved overall survival in the total cohort (HR, 0.46; 95% CI, 0.31-0.68; P=0.0001). When comparing survival by surgical type, receipt of adjuvant radiation significantly improved survival in the lumpectomy group (HR, 0.30; 95% CI, 0.16-0.58; P=0.0004), but was not associated with improved survival in the SM group (HR, 0.38; 95% CI, 0.05-3.04; P=0.36) or in the MRM group (HR, 0.79; 95% CI, 0.46-1.34; P=0.38). The survival benefit of adjuvant radiation in these TNBC patients is attributed to those undergoing breast-conserving therapy. There was no benefit in either mastectomy group. These data warrant validation from prospective trials, in order to develop tailored locoregional treatment for patients with TNBC.