State of Physician Unionization.

OBJECTIVES: To provide an overview of the current state of physician unionization, potential factors surrounding increased unionization, and the ethical and financial issues that may arise. DESIGN: Review article. SETTING: Not applicable. PARTICIPANTS: Not applicable. RESULTS: Over the last few years, there has been a recent surge in physician unionization. Union membership among residents and fellows is also at an all-time high and continues to increase, as seven residency programs voted to unionize in 2023. The resulting threat of strikes has grown considerably over the last year as residents across 6 hospitals have threatened to strike, resulting in New York's first physician strike in over three decades. As physician practice continues to shift from private to corporate health system-based employment, more opportunities for unionization will arise. Globally, these trends have been comparable, with thousands of physicians striking across the United Kingdom, Germany, Italy, Nigeria, and New Zealand in the last year. CONCLUSION: The current state of physician unionization is of increasing significance as more physicians are presented with opportunities for unionization. Physicians perceive a lack of autonomy, and the demand to deliver high level outcomes with diminishing resources is becoming an insurmountable challenge. Additionally, physician satisfaction with their workplace has decreased with increased burnout rates. Thus, it is important to understand the current state of unionization, potential reasons for unionization among physicians and residents, and its future impact on the field of medicine.

Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors.

BACKGROUND: Over the last decade, a greater number of transgender or non-binary (TGNB) minors have been seeking gender affirmation surgery (GAS). Given the recent concerns about the potential harm of GAS in TGNB minors, we sought to determine the incidence and postoperative outcomes of GAS among TGNB minors. METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database, 2018-2021, for minors aged 17 years or younger. The primary outcome was the frequency and type of GAS plotted over time. The secondary outcome was the incidence of postoperative complications within 30 days following GAS. Descriptive statistics were calculated. Linear regression was performed to assess the association between the incidence of GAS and time in years. RESULTS: A total of 108 TGNB minors were identified. The mean (SD) age was 16.9 (0.8) years without significant variation over time. There was a significant increase in the number of GAS per year over four years (P<.001). Nevertheless, only two (1.9%) patients underwent GAS below the age of 15 (13.9 and 14.5 years). Chest masculinization surgery (CMS) was the predominant procedure type among TGNB minors (n=102, 94.4%). There was no incidence of major complications (mortality, bleeding, sepsis, unplanned intubation) except for unplanned reoperation for hematoma evacuation (n=3, 2.8%). The incidence of minor complications (surgical site infection, wound dehiscence) was low (n=1, 0.9%), each). CONCLUSIONS AND RELEVANCE: GAS in minors, primarily in the form of CMS, has been increasing over time. CMS in minors is a safe procedure with rare complications.

Laparoscopic management of combined cholecystogastric and cholecystocolonic fistulae.

Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.

Inhalation Injury Grading Using Transfer Learning Based on Bronchoscopy Images and Mechanical Ventilation Period.

The abbreviated injury score (AIS) is commonly used as a grading system for inhalation injuries. While inhalation injury grades have inconsistently been shown to correlate positively with the time mechanical ventilation is needed, grading is subjective and relies heavily on the clinicians' experience and expertise. Additionally, no correlation has been shown between these patients' inhalation injury grades and outcomes. In this paper, we propose a novel inhalation injury grading method which uses deep learning algorithms in bronchoscopy images to determine the injury grade from the carbonaceous deposits, blistering, and fibrin casts in the bronchoscopy images. The proposed method adopts transfer learning and data augmentation concepts to enhance the accuracy performance to avoid overfitting. We tested our proposed model on the bronchoscopy images acquired from eighteen patients who had suffered inhalation injuries, with the degree of severity 1, 2, 3, 4, 5, or 6. As performance metrics, we consider accuracy, sensitivity, specificity, F-1 score, and precision. Experimental results show that our proposed method, with both transfer learning and data augmentation components, provides an overall 86.11% accuracy. Moreover, the experimental results also show that the performance of the proposed method outperforms the method without transfer learning or data augmentation.

Two surgeons' collaboration to close an extreme open abdomen with loss of domain utilizing the abdominal dynamic tissue system and porcine urinary bladder matrix.

Acute open abdomen with loss of domain is an extremely difficult surgical scenario, and secondary complications are common. This case describes a 33-year-old woman who initially underwent an elective, laparoscopic endometrioma resection during which a complete iatrogenic transection of the left ureter and part of the sigmoid mesentery occurred. After discharge 5 days later, she was immediately readmitted for worsening abdominal pain. During the emergency abdominal reexploration, an ischemic, perforated sigmoid colon was removed and large volume paracentesis was performed due to fecal contamination. Nine additional reexplorations over 2 months resulted in an extreme acute open abdomen with loss of domain. Viscera was protected with negative pressure wound therapy, but primary myofascial closure was not feasible. Through surgical collaboration between two institutions, an abdominal dynamic tissue system was installed, which achieved primary myofascial closure 31 days after installation. Nine days later, complete wound closure utilizing porcine urinary bladder matrix was accomplished. This case highlights the successful achievement of primary myofascial closure and complete wound healing without a surgical site infection or hernia development in this heavily contaminated abdomen using dynamic tissue system biomechanics with porcine urinary bladder matrix biologics.

Vitamin A-Induced Hypercalcemia in Burn Patients: A Case Study.

Vitamin and steroid supplementation such as oxandrolone are commonly given to speed the recovery process in severe burn injuries. Vitamin A is administered concurrently with steroids because of its pro-inflammatory and positive effects on wound healing. However, vitamin A supplementation warrants caution as hypercalcemia can result from vitamin A overdose. Our case involves an 18-year-old male injured in an oil field explosion who presented with 55% total body surface area (TBSA) partial- and full-thickness burns. Following successful resuscitation, he was given vitamin A, oxandrolone, vitamin C, and zinc sulfate as part of the standard vitamin supplementation. On hospital day (HD) 33, serum calcium levels were noted to be elevated and increased to 13 mg/dL a few days later. Parathyroid hormone and vitamin D levels were found to be within normal range, and urine analysis showed normal calcium excretion. Subsequent assessment of vitamin A levels revealed significantly elevated levels at 93 mcg/dL. Vitamin A supplementation was discontinued, and the patient was discharged on HD 42. At the 1-month follow-up, serum calcium levels were normal, which links the hypercalcemia to vitamin A overdose. This case highlights the importance of considering vitamin A overdose as a cause for asymptomatic hypercalcemia with a normal parathyroid and vitamin D workup. While routine, vitamin A supplementation in burn patients calls for assessment of both serum calcium and vitamin A levels throughout the hospital stay to prevent hypercalcemia and its negative effects.