Possible effect of exercise with anti-fatigue nutrition on ROS-induced depression and suicide risk: a review.

PURPOSE: Epidemiological evidence shows that physical activity, including continuous stimulus changes and appropriate exercise programs, improves brain degeneration in the hippocampus, prefrontal cortex (PFC), and anterior cingulate cortex (ACC). Therefore, we investigated the possible synergistic effects of physical activity and nutrition in controlling chronic fatigue and reducing oxidative stress in patients at risk for depression and suicide. METHODS: We systematically reviewed the literature on various systemic factors related to the effects of 1) suppressing oxidative stress and 2) improving depression through exercise and nutrition. To conduct this review, we searched the PubMed database for papers published until May 1, 2024, using the terms "physical activity OR exercise" and "fatigue" OR "anti-fatigue," "oxidative stress" and "depression" and "suicide." We then reviewed the resulting list of articles related to antioxidant mechanisms. RESULTS: Appropriate physical activity and natural product intake can substantially change whole-body homeostasis and provide a way to overcome the threat of depression and suicide by regulating metabolites, scavenging free radicals, and neurotransmitters. CONCLUSION: Suicide and depression prevention play crucial roles in improving patients' quality of life. Our review provides evidence supporting the idea that exercise and antioxidant nutrition diminish oxidative stress and fatigue by improving the degeneration of the hippocampus, PFC, and ACC.

Changes on Non-contrast MRI Following Lymphatic Surgery for Upper Extremity Secondary Lymphedema.

OBJECTIVE: To assess changes in non-contrast MRI-based biomarkers following upper extremity lymphedema surgery. METHODS: We retrospectively identified secondary upper extremity lymphedema patients who underwent vascularized lymph node transplant (VLNT), debulking lipectomy, or VLNT with a prior debulking (performed separately). All patients with both pre- and post-surgical MRIs were compared. An MRI-based edema scoring system was used: 0 (no edema), 1 (less than 50% fluid from myofascial to dermis), and 2 (50% or greater fluid from myofascial to dermis). Edema scores and subcutaneous thickness (ST) were obtained along four quadrants across the upper and lower third of the arm and forearm each-for a total of 16 anatomical locations-and compared before and after surgery. Net changes in edema scores and ST were then correlated with LYMPH-Q (quality of life) scores, L-Dex (bioimpedance), and limb volume difference by perometry. RESULTS: Patients who underwent lymphatic surgeries between January 2017-December 2022 and successfully completed pre- and post-surgery MRI were included, resulting in a total of 33 unilateral secondary upper extremity lymphedema patients (age 63 ± 14 years, 32 Female). The median range post-operative follow-up times were 12.5 [6-19] months for VLNT, 13.5 [12-40] months for debulking, and 12.0 [12-24] months for patients who underwent VLNT following debulking surgery. There was a decrease in mean subcutaneous thickness (ST) in 15 of 16 anatomical segments of the upper extremity following debulking (p<.001), while edema score increased in 7 of 16 segments (p≤02). Edema stage did not change in patients who underwent VLNT-only or VLNT following debulking. ST decreased only along the radial forearm in patients who underwent VLNT following debulking despite an improvement in LYMPQOL in the former group. There was correlation between a decrease in ST with a decrease in volume within the debulking group (r=0.79, p<.001). A reduction in ST also correlated with improved LYMQOL in the debulking group (r=0.49, p=0.04). CONCLUSION: A reduction in subcutaneous thickness was demonstrated in most anatomical segments following liposuction debulking, while edema stage was increased. Fewer changes were seen with VLNT, possibly a reflection of more gradual changes within this short follow-up period, with the radial forearm potentially revealing the earliest response.

Enhancing Post-Mastectomy Care: Telehealth's Impact on Breast Reconstruction Accessibility for Breast Cancer Patients.

OBJECTIVE: To examine how the recent sharp rise in telemedicine has impacted trends in accessibility of breast reconstruction (BR). PATIENTS AND METHODS: A retrospective study reviewed patients who underwent a total mastectomy at our institution from 1 August 2016 to 31 January 2022. By comparing cohorts before and during the widespread implementation of telemedicine, we assessed telehealth's impact on healthcare accessibility, measured by distance from patients' residences to our institution. RESULTS: A total of 359 patients were included in this study. Of those, 176 received total mastectomy prior to the availability of telemedicine, and 183 in the subsequent period. There were similar baseline characteristics among patients undergoing mastectomy, including distance from place of residence to hospital (p = 0.67). The same proportion elected to receive BR between groups (p = 0.22). Those declining BR traveled similar distances as those electing the procedure, both before the era of widespread telemedicine adoption (40.3 and 35.6 miles, p = 0.56) and during the height of telemedicine use (22.3 and 61.3 miles, p = 0.26). When tracking follow-up care, significantly more patients during the pandemic pursued at least one follow-up visit with their original surgical team, indicative of the increased utilization of telehealth services. CONCLUSIONS: While the rate of BR remained unchanged during the pandemic, our findings reveal significant shifts in healthcare utilization, highly attributed to the surge in telehealth adoption. This suggests a transformative impact on breast cancer care, emphasizing the need for continued exploration of telemedicine's role in enhancing accessibility and patient follow-up in the post-pandemic era.

Exploring Pediatric Code Status, Advance Care Planning, and Mode of Death Disparities at End of Life.

CONTEXT: Children from marginalized groups are at risk for worse medical outcomes, yet little is known about their end of life experiences. OBJECTIVE: We examine the characteristics of deceased children with a focus on race, ethnicity, and preferred language. METHODS: We conducted a cross-sectional study of patients who died at Texas Children's Hospital from 2018 to 2019. Demographics, date of death, and final code status were extracted. Medical complexity prior to admission and mode of death were obtained from chart review. RESULTS: We included 433 patients. Over one-third were Hispanic (39.3%) with 42.3% preferring Spanish. The majority were White (61.4%) or Black (21.0%). Most patients had significant medical complexity (52.0%) or were infants in their birth admission (29.4%). Half (52.4%) received palliative care; patients with increased medical complexity were more likely to have palliative care involved (P<0.001). There were no differences in palliative care, code status, or mode of death by race. Hispanic patients were less likely to have a full code status (OR 0.42, 95% CI: 0.25-0.73). Spanish-speaking patients were more likely to have palliative care involvement (OR 2.05, 95% CI: 1.21-3.46) and less likely full code orders (OR 0.24, 95% CI: 0.1-0.63). CONCLUSION: Palliative care services are engaged with most children at end of life and is accessible to marginalized patient groups. Spanish-speaking patients have different code status orders and modes of death at end of life. Further studies are needed to elucidate explanatory factors for differences revealed and multicenter studies are needed to characterize more widespread experiences.

An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures.

BACKGROUND: Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. METHODS: A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. RESULTS: From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. CONCLUSION: Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.

Is Everyone Beating Around the Bush?: A Qualitative Study Examining the Status of Shared Decision-Making Between Veterans Affairs Providers and Surgical Patients in the ICU.

Objective: We sought to determine if and how providers use elements of shared decision-making (SDM) in the care of surgical patients in the intensive care unit (ICU). Background: SDM is the gold standard for decision-making in the ICU. However, it is unknown if this communication style is used in caring for critically ill surgical patients. Methods: Qualitative interviews were conducted with providers who provide ICU-level care to surgical patients in Veterans Affairs hospitals. Interviews were designed to examine end-of-life care among veterans who have undergone surgery and require ICU-level care. Results: Forty-eight providers across 14 Veterans Affairs hospitals were interviewed. These participants were diverse with respect to age, race, and sex. Participant dialogue was deductively mapped into 8 established SDM components: describing treatment options; determining roles in the decision-making process; fostering partnerships; health care professional preferences; learning about the patient; patient preferences; supporting the decision-making process; and tailoring the information. Within these components, participants shared preferred tools and tactics used to satisfy a given SDM component. Participants also noted numerous barriers to achieving SDM among surgical patients. Conclusions: Providers use elements of SDM when caring for critically ill surgical patients. Additionally, this work identifies facilitators that can be leveraged and barriers that can be addressed to facilitate better communication and decision-making through SDM. These findings are of value for future interventions that seek to enhance SDM among surgical patients both in the ICU and in other settings.

Association of Metabolic Derangement and Postoperative Outcomes in Hernia Repair With Component Separation: A Propensity Score-matched Nationwide Analysis.

INTRODUCTION: Metabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T-tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups. RESULTS: After propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups. CONCLUSIONS: The presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS.

Duration of New-Onset Depressive Symptoms During Medical Residency.

Importance: The implications of new-onset depressive symptoms during residency, particularly for first-year physicians (ie, interns), on the long-term mental health of physicians are unknown. Objective: To examine the association between and persistence of new-onset and long-term depressive symptoms among interns. Design, Setting, and Participants: The ongoing Intern Health Study (IHS) is a prospective annual cohort study that assesses the mental health of incoming US-based resident physicians. The IHS began in 2007, and a total of 105 residency programs have been represented in this national study. Interns enrolled sequentially in annual cohorts and completed follow-up surveys to screen for depression using the 9-item Patient Health Questionnaire-9 (PHQ-9) throughout and after medical training. The data were analyzed from May 2023 to March 2024. Exposure: A positive screening result for depression, defined as an elevated PHQ-9 score of 10 or greater (indicating moderate to severe depression) at 1 or more time points during the first postgraduate year of medical training (ie, the intern year). Main Outcomes and Measures: The main outcomes assessed were mean PHQ-9 scores (continuous) and proportions of physicians with an elevated PHQ-9 score (≥10; categorical or binary) at the time of the annual follow-up survey. To account for repeated measures over time, a linear mixed model was used to analyze mean PHQ-9 scores and a generalized estimating equation (GEE) was used to analyze the binary indicator for a PHQ-9 score of 10 or greater. Results: This study included 858 physicians with a PHQ-9 score of less than 10 before the start of their internship. Their mean (SD) age was 27.4 (9.0) years, and more than half (53.0% [95% CI, 48.5%-57.5%]) were women. Over the follow-up period, mean PHQ-9 scores did not return to the baseline level assessed before the start of the internship in either group (those with a positive depression screen as interns and those without). Among interns who screened positive for depression (PHQ-9 score ≥10) during their internship, mean PHQ-9 scores were significantly higher at both 5 years (4.7 [95% CI, 4.4-5.0] vs 2.8 [95% CI, 2.5-3.0]; P < .001) and 10 years (5.1 [95% CI, 4.5-5.7] vs 3.5 [95% CI, 3.0-4.0]; P < .001) of follow-up. Furthermore, interns with an elevated PHQ-9 score (≥10) demonstrated a higher likelihood of meeting this threshold during each year of follow-up. Conclusions and Relevance: In this cohort study of IHS participants, a positive depression screening result during the intern year had long-term implications for physicians, including having persistently higher mean PHQ-9 scores and a higher likelihood of meeting this threshold again. These findings underscore the pressing need to address the mental health of physicians who experience depressive symptoms during their training and to emphasize the importance of interventions to sustain the health of physicians throughout their careers.

Pop-Up Safety Town: Leveling the Playing Field for Children in Underserved Communities Through Injury Prevention Education.

BACKGROUND: Unintentional injuries are the leading cause of morbidity and mortality among children and adolescents in the United States. Traditional injury education interventions for children often are inaccessible due to cost and logistics in underserved communities, exacerbating injury disparities. A new approach is needed to close this gap for families with preschool children. CONTRIBUTIONS TO THEORY: Collaborating with Head Start preschools optimizes engagement and accessibility to families in underserved communities. Involving caregivers and community organizations addresses the limitations of conventional interventions and community-specific injury prevention concerns. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Pop-up Safety Town offers a more affordable model for injury prevention education, particularly in underserved regions. The model's approach, using adaptable education, mobile and reusable materials, and volunteer staffing, offers greater potential for achieving sustainable impact in these underserved communities. CONCLUSIONS: Pop-up Safety Town presents a novel upstream solution to address disparities in injury prevention education in underserved communities.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Development of "Explore Plastic Surgery": An Educational Program for Medical Students Without Home Residency Programs.

BACKGROUND: Medical students who attend institutions without plastic surgery residency programs are at a disadvantage in the plastic surgery match. We developed an educational program for medical students without home programs called Explore Plastic Surgery to provide an overview of the steps toward a career in plastic surgery. The purpose of this study was to assess the impact, utility, and success of the novel program. METHODS: Pre- and postevent surveys were distributed to participants. Survey data were analyzed including participant demographics, perceptions of barriers unique to those without home programs, and the overall event utility. RESULTS: Two hundred seventeen students registered for the program. Ninety-five participants completed the pre-event survey (44%), and of those, 57 participants completed the post-event survey (60%). There was an increase in understanding of the steps toward a career in plastic surgery ( P < 0.001), confidence in overcoming barriers ( P = 0.005), and level of comfort in reaching out to faculty for opportunities ( P = 0.01). There was a decrease in the perceived negative impact that attending medical schools without a home program will have on their abilities to pursue careers in plastic surgery ( P = 0.006). CONCLUSIONS: After the event, participants demonstrated an increase in their confidence in overcoming barriers and a decrease in their perceptions that attending an institution without a home program would negatively impact their ability to pursue plastic surgery. Initiatives focused on early exposure and recruitment of medical students may be important to promote accessibility and diversity within plastic surgery.

Barriers of Three-Dimensional Printing in Craniofacial Plastic Surgery Practice: A Pilot Study and Literature Review.

OBJECTIVE: Three-dimensional printing (3Dp) and modeling have demonstrated increasing utility within plastic and reconstructive surgery (PRS). This study aims to understand the prevalence of how this technology is utilized in craniofacial surgery, as well as identify barriers that may limit its integration into practice. METHODS: A survey was developed to assess participant demographics, characteristics of 3Dp use, and barriers to utilizing three-dimensional technologies in practice. The survey was distributed to practicing craniofacial surgeons. A secondary literature review was conducted to identify solutions for barriers and potential areas for innovation. RESULTS: Fifteen complete responses (9.7% response rate) were analyzed. The majority (73%) reported using three-dimensional modeling and printing in their practice, primarily for surgical planning. The majority (64%) relied exclusively on outside facilities to print the models, selecting resources required to train self and staff (55%), followed by the cost of staff to run the printer (36%), as the most common barriers affecting 3Dp use in their practice. Of those that did not use 3Dp, the most common barrier was lack of exposure (75%). The literature review revealed cost-lowering techniques with materials, comparability of desktop commercial printers to industrial printers, and incorporation of open-source software. CONCLUSIONS: The main barrier to integrating 3Dp in craniofacial plastic and reconstructive surgery practice is the perceived cost associated with utilizing the technology. Ongoing literature highlights the cost-utility of in-house 3Dp technologies and practical cost-saving methods. The authors' results underscore the need for broad exposure for currently practicing attendings and trainees in 3Dp practices and other evolving technologies.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND: The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. METHODS: A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. RESULTS: Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). CONCLUSIONS: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

The Impact of Health Literacy on Trust in Online Plastic Surgery Content: A Nationwide Analysis.

INTRODUCTION: On most online platforms, just about anyone can disseminate plastic surgery (PS) content regardless of their educational or professional background. This study examines the general public's perceptions of the accuracy of online PS content and the factors that contribute to the discernment of credible information. METHODS: The Amazon Mechanical Turk crowdsourcing platform was used to survey adults in the United States. The survey assessed respondent demographics, health literacy (HL), and perceptions of online PS content accuracy. T-tests, Chi-square tests, and post hoc analyses with Bonferroni corrections assessed differences between HL groups. Multivariate linear regressions assessed associations between sociodemographic variables and perceptions of online content. RESULTS: In total, 428 (92.0%) of 465 complete responses were analyzed. The median age of respondents was 32 y (interquartile range: 29-40). Online sources were predominantly perceived to have a high degree of accuracy, with mean scores of various platforms ranging from 3.8 to 4.5 (1 = not accurate at all; 5 = extremely accurate). The low HL group perceived social media sites and review sites to be more accurate than the high HL respondents, particularly for Reddit (P = 0.004), Pinterest (P = 0.040), and Snapchat (P = 0.002). CONCLUSIONS: There is a concerning relationship between low HL and the perceptions of the accuracy of online PS sources. This study underscores the need for education campaigns, the development of trustworthy online resources, and initiatives to improve HL. By fostering a more informed public, individuals seeking PS can make better informed decisions.

Gender differences in ergonomics during simulated ureteroscopy.

BACKGROUND: Female urologists report higher rates of work-related physical discomfort compared to male urologists. We compared ergonomics during simulated ureteroscopy, the most common surgery for kidney stones, between male and female urologists. METHODS: Surface electromyography was used to measure muscle activation during common ureteroscopic tasks in urology trainees and staff with different surgeon positions and ureteroscopes. Subjective workload was assessed using the NASA Task Load Index (NASA-TLX). Paired t-tests, Wilcoxon rank-sum tests, and multivariate regressions were used to compare muscle activation by gender for each trial condition. RESULTS: There was no difference in age or distribution of training level between genders, though men had larger glove sizes. Across all conditions, women required greater muscle activation in multiple muscle groups and had greater NASA-TLX scores compared to men. CONCLUSIONS: There may be gender differences in ergonomics during ureteroscopy based on muscle activation and subjective workload, suggesting potential for personalizing surgical ecosystems.

A National Analysis of Targeted Muscle Reinnervation Following Major Upper Extremity Amputation.

BACKGROUND: Post-amputation pain is a debilitating sequela of upper extremity (UE) amputation. Targeted muscle reinnervation (TMR) is a relatively novel treatment that can help prevent pain and improve quality of life. The purpose of this study is to evaluate national trends in the application of immediate TMR following UE amputations.   . METHODS: An analysis of the Nationwide Inpatient Sample database was conducted from 2016-2019. ICD-10 codes were used to identify encounters involving UE amputation with and without TMR. NIS weights were used to estimate national estimates of incidence. Patient-specific and hospital-specific factors were analyzed to assess associations with use of TMR. RESULTS: A total of 8,945 weighted encounters underwent UE amputation, and of those, only 310 (3.5%) received TMR. The majority of TMR occurred in urban hospitals (>95%). Younger patients (47 vs. 54, p=0.008) and patients located in New England were significantly more likely to receive TMR. There was no difference in total cost of hospitalization amongst patients who received TMR ($55,241 vs $59,027.8, p=0.683) but significantly shorter lengths of hospital stay when receiving TMR versus other management (10.6 vs. 14.8, p=0.012). CONCLUSIONS: TMR has purported benefits of pain reduction, neuroma prevention, and increased prosthetic control. Access to this beneficial procedure following UE amputation varies by demographics and geographic region. Given that TMR has not been shown to increase cost while simultaneously decreasing patient length of stay, increased efforts to incorporate this procedure into training and practice will help to ensure equitable care for amputation patients. .

The impact of race and ethnicity in outpatient breast reconstruction decision-making and postoperative outcomes: A propensity score-matched NSQIP analysis.

BACKGROUND: Recent literature has established outpatient breast reconstruction (BR) to be a safe alternative to inpatient BR. However, the impact of race and ethnicity on BR patient decision-making and postsurgical outcomes remains unexplored. This study aims to assess the impact of race and ethnicity on outpatient BR timing and postoperative complication rates. METHODS: The 2013-2020 ACS-NSQIP database was utilized to identify women undergoing outpatient BR. Propensity score-matched analysis was conducted to generate balanced cohorts based on race and ethnicity. t-tests and Fisher's exact tests were used to assess group differences. Logistic regressions were modeled to evaluate differences in complications between groups. RESULTS: A total of 63,526 patients underwent outpatient BR. After propensity score matching, 7664 patients and 3948 patients were included in the race and ethnicity-based analysis, respectively. There were statistically significant differences in the timing of BR patients received across cohorts. NW patients had lower rates of immediate BR (IBR) compared with White patients (47% vs. 53%, p < 0.001), and this also was seen in Hispanic patients (97% vs. 3%, p = 0.018). Subsequently, there were higher rates of delayed BR (DBR) in the NW cohort (55% vs. 45%, p < 0.001) and in the Hispanic cohort (95% vs. 5%, p = 0.018). There were no significant differences in the rates of 30-day postoperative complications across cohorts. CONCLUSIONS: Ultimately, our findings suggest that minority patients are more likely to undergo DBR than nonminority patients. However, there were no differences in 30-day postoperative outcomes across race or ethnicity. Future studies to elucidate patients' decision-making process in choosing optimal BR types and timing are necessary to better understand the impact of the observed differences in patient care.

Pragmatic trial evaluating the impact of simulation training on high-risk prescribing to older adults by junior physicians.

BACKGROUND: High-risk medications like benzodiazepines, sedative hypnotics, and antipsychotics are commonly prescribed for hospitalized older adults, despite guidelines recommending avoidance. Prior interventions have not fully addressed how physicians make such prescribing decisions, particularly when experiencing stress or cognitive overload. Simulation training may help improve prescribing decision-making but has not been evaluated for overprescribing. METHODS: In this two-arm pragmatic trial, we randomized 40 first-year medical resident physicians (i.e., interns) on inpatient general medicine services at an academic medical center to either intervention (a 40-minute immersive simulation training) or control (online educational training) groups. The primary outcome was the number of new benzodiazepine, sedative hypnotic, or antipsychotic orders for treatment-naïve older adults during hospitalization. Secondary outcomes included the same outcome by all providers, being discharged on one of the medications, and orders for related or control medications. Outcomes were measured using electronic health record data over each intern's service period (~2 weeks). Outcomes were evaluated using generalized estimating equations, adjusting for clustering. RESULTS: In total, 522 treatment-naïve older adult patients were included in analyses. Over follow-up, interns prescribed ≥1 high-risk medication for 13 (4.9%) intervention patients and 13 (5.0%) control patients. The intervention led to no difference in the number of new prescriptions (Rate Ratio [RR]: 0.85, 95%CI: 0.31-2.35) versus control and no difference in secondary outcomes. In secondary analyses, intervention interns wrote significantly fewer "as-needed" ("PRN") order types for the high-risk medications (RR: 0.29, 95%CI: 0.08-0.99), and instead tended to write more "one-time" orders than control interns, though this difference was not statistically significant (RR: 2.20, 95%CI: 0.60-7.99). CONCLUSIONS: Although this simulation intervention did not impact total high-risk prescribing for hospitalized older adults, it did influence how the interns prescribed, resulting in fewer PRN orders, suggesting possibly greater ownership of care. Future interventions should consider this insight and implementation lessons raised. TRIAL REGISTRATION: Clinicaltrials.gov(NCT04668248).

Look at Grandma! Joint visual attention over video chat during the COVID-19 pandemic.

Social interactions are crucial for many aspects of development. One developmentally important milestone is joint visual attention (JVA), or shared attention between child and adult on an object, person, or event. Adults support infants' development of JVA by structuring the input they receive, with the goal of infants learning to use JVA to communicate. When family members are separated from the infants in their lives, video chat sessions between children and distant relatives allow for shared back-and-forth turn taking interaction across the screen, but JVA is complicated by screen mediation. During video chat, when a participant is looking or pointing at the screen to something in the other person's environment, there is no line of sight that can be followed to their object of focus. Sensitive caregivers in the remote and local environment with the infant may be able to structure interactions to support infants in using JVA to communicate across screens. We observed naturalistic video chat interactions longitudinally from 50 triads (infant, co-viewing parent, remote grandmother). Longitudinal growth models showed that JVA rate changes with child age (4 to 20 months). Furthermore, grandmother sensitivity predicted JVA rate and infant attention. More complex sessions (sessions involving more people, those with a greater proportion of across-screen JVA, and those where infants initiated more of the JVA) resulted in lower amounts of JVA-per-minute, and evidence of family-level individual differences emerged in all models. We discuss the potential of video chat to enhance communication for separated families in the digital world.

A needs assessment for simulation in African surgical education.

INTRODUCTION: There is a critical need for comprehensive surgical training in African countries given the unmet surgical burden of disease in this region. Collaborative and progressive initiatives in global surgical education will have the greatest impact on trainees. Little is known about surgical education needs from the perspective of practicing surgeons and trainees in low-middle-income countries (LMICs). Even less is known about the potential role for simulation to augment training. METHODS: A modified Delphi methodology with 2 rounds of responses was employed to survey program directors (PD) and associate program directors (APD) of Pan-African Association of Christian Surgeons (PAACS) general surgery residency programs across eight low-middle-income countries in Africa. 3 PD/APDs and 2 surgical residents participated in semi-structured interviews centered around the role of simulation in training. Descriptive analysis was performed to elicit key themes and illustrative examples. RESULTS: The survey of program directors revealed that teaching residents the psychomotor skills need to perform intracorporeal suturing was both high priority and desired in multiple training sites. Other high priority skills were laparoscopic camera driving and medial visceral rotation. The interviews revealed a specific desire to perform laparoscopic surgery and a need for a simulation curriculum to familiarize staff and trainees with laparoscopic techniques. Several barriers to laparoscopic surgery exist, such as lack of staff familiarity with the equipment, lack of public buy in, and lack of generalizable and adaptable educational modules. Trainees saw utility in the use of simulation to optimize time in the operating room and sought opportunities to improve their laparoscopic skills. CONCLUSION: Faculty and surgical trainees in LMICs have interest in learning advanced surgical techniques, such as laparoscopy. Developing a simulation curriculum tailored to the trainees' local context has the potential to fill this need.