Overcoming Barriers: Sex Disparity in Surgeon Ergonomics.

BACKGROUND: Musculoskeletal discomfort is widely experienced by surgeons across multiple surgical specialties. Developing technologies and new minimally invasive techniques add further complexity and ergonomic stressors. These stressors differentially affect male and female surgeons, but little is known about the role these sex disparities play in surgical ergonomic stress. We reviewed existing literature to better understand how ergonomic stress varies between male and female surgeons. STUDY DESIGN: A literature search was performed via PubMed including but not limited to the following topics: ergonomics, surgeons, female surgeons, women surgeons, pregnancy, and operating room. A review of available quantitative data was performed. RESULTS: Female surgeons endure more pronounced ergonomic discomfort than their male counterparts, with added ergonomic stress associated with pregnancy. CONCLUSIONS: A 4-fold method is proposed to overcome ergonomic barriers, including (1) improved education on prevention and treatment of ergonomic injury for active surgeons and trainees, (2) increased departmental and institutional support for ergonomic solutions for surgeons, (3) partnerships with industry to study innovative ergonomic solutions, and (4) additional research on the nature of surgical ergonomic challenges and the differential effects of surgical ergonomics on female surgeons.

Clinical presentation, outcomes, and threshold for repair by sex in degenerative saccular vs fusiform aneurysms in the descending thoracic aorta.

OBJECTIVE: Saccular-shaped thoracic aortic aneurysms (TAAs) are often treated at smaller diameters compared with fusiform TAAs, despite a lack of strong clinical evidence to support this practice. The aim of this study was to examine differences in presentation, treatment, and outcomes between saccular TAAs and fusiform TAAs in the descending thoracic aorta. We also examined the need for sex-specific treatment thresholds for TAAs. METHODS: All Vascular Quality Initiative (VQI) patients undergoing thoracic endovascular aneurysm repair (TEVAR) for degenerative TAAs in the descending thoracic aorta from 2012 through 2022 were reviewed. Patients were stratified by urgency: emergent/urgent vs elective repairs (ruptured/symptomatic). Demographics, comorbidities, anatomical/procedural characteristics, and outcomes for fusiform TAAs and saccular TAAs were compared. Cumulative distribution curves were used to plot the proportion of patients who underwent emergent/urgent repair according to sex-stratified aortic diameter. RESULTS: Among 655 emergent/urgent TEVARs, 37% were performed for saccular TAAs, whereas among 1352 elective TEVARs, 35% had saccular TAA morphology. Compared with fusiform TAAs, saccular TAAs more frequently underwent emergent/urgent (ruptured/symptomatic) TEVAR below the repair threshold in both females (<50 mm: 38% vs 10%; relative risk, 3.39; 95% confidence interval [CI], 2.04-5.70; P < .001), and males (<55 mm: 47% vs 21%; relative risk, 2.26; 95% CI, 1.60-3.18; P < .001). Moreover, among patients with emergent/urgent fusiform TAAs, females presented at smaller diameters compared with males, whereas there was no difference in preoperative aneurysm diameter among patients with saccular TAAs. Regarding outcomes, emergent/urgent treated saccular TAAs had similar postoperative outcomes and 5-year mortality compared with fusiform TAAs. Nevertheless, in the elective cohort, patients with saccular TAAs had similar postoperative mortality compared with those with fusiform TAAs, but a lower rate of postoperative spinal cord ischemia (0.7% vs 3.2%; P = .010). Furthermore, patients with saccular TAAs had a higher rate of 5-year mortality compared with their fusiform counterparts (23% vs 17%; hazard ratio, 1.53; 95% CI, 1.12-2.10; P = .010). CONCLUSIONS: Patients with saccular TAAs underwent emergent/urgent TEVAR at smaller diameters than those with fusiform TAAs, supporting current clinical practice guideline recommendations that saccular TAAs warrant treatment at smaller diameters. Furthermore, these data support a sex-specific treatment threshold for patients with fusiform TAAs, but not for those with saccular TAAs. Although there were no differences in outcomes following TEVAR between morphologies in the emergent/urgent cohort, patients with saccular TAAs who were treated electively were associated with higher 5-year mortality compared with those with fusiform TAAs.

Comparison of Male and Female Surgeons' Experiences With Gender Across 5 Qualitative/Quantitative Domains.

Importance: A growing body of literature has been developed with the goal of attempting to understand the experiences of female surgeons. While it has helped to address inequities and promote important programmatic improvements, work remains to be done. Objective: To explore how practicing male and female surgeons' experiences with gender compare across 5 qualitative/quantitative domains: career aspirations, gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change. Design, Setting, and Participants: This national concurrent mixed-methods survey of Fellows of the American College of Surgeons (FACS) compared differences between male and female FACS. Differences between female FACS and female members of the Association of Women Surgeons (AWS) were also explored. A randomly selected 3:1 sample of US-based male and female FACS was surveyed between January and June 2020. Female AWS members were surveyed in May 2020. Exposure: Self-reported gender. Main Outcomes and Measures: Self-reported experiences with career aspirations (quantitative), gender-based discrimination (quantitative), mentor-mentee relationships (quantitative), perceived barriers (qualitative), and recommendations for change (qualitative). Results: A total of 2860 male FACS (response rate: 38.1% [2860 of 7500]) and 1070 female FACS (response rate: 42.8% [1070 of 2500]) were included, in addition to 536 female AWS members. Demographic characteristics were similar between randomly selected male and female FACS, with the notable exception that female FACS were less likely to be married (720 [67.3%] vs 2561 [89.5%]; nonresponse-weighted P < .001) and have children (660 [61.7%] vs 2600 [90.9%]; P < .001). Compared with female FACS, female AWS members were more likely to be younger and hold additional graduate degrees (320 [59.7%] were married; 238 [44.4%] had children). FACS of both genders acknowledged positive and negative aspects of dealing with gender in a professional setting, including shared experiences of gender-based harassment, discrimination, and blame. Female FACS were less likely to have had gender-concordant mentors. They were more likely to emphasize the importance of gender when determining career aspirations and prioritizing future mentor-mentee relationships. Moving forward, female FACS emphasized the importance of avoiding competition among female surgeons. They encouraged male surgeons to acknowledge gender bias and admit their potential role. Male FACS encouraged male and female surgeons to treat everyone the same. Conclusions and Relevance: Experiences with gender are not limited to supportive female surgeons. The results of this study emphasize the importance of recognizing the voices of all stakeholders involved when striving to promote workforce diversity and the related need to develop quality improvement/surgical education initiatives that enhance inclusion through open, honest discourse.

Fatigue in incident peritoneal dialysis and mortality: A real-world side-by-side study in Brazil and the United States.

BACKGROUND: We tested if fatigue in incident Peritoneal Dialysis associated with an increased risk for mortality, independently from main confounders. METHODS: We conducted a side-by-side study from two of incident PD patients in Brazil and the United States. We used the same code to independently analyze data in both countries during 2004 to 2011. We included data from adults who completed KDQOL-SF vitality subscale within 90 days after starting PD. Vitality score was categorized in four groups: >50 (high vitality), ≥40 to ≤50 (moderate vitality), >35 to <40 (moderate fatigue), ≤35 (high fatigue; reference group). In each country's cohort, we built four distinct models to estimate the associations between vitality (exposure) and all-cause mortality (outcome): (i) Cox regression model; (ii) competing risk model accounting for technique failure events; (iii) multilevel survival model of clinic-level clusters; (iv) multivariate regression model with smoothing splines treating vitality as a continuous measure. Analyses were adjusted for age, comorbidities, PD modality, hemoglobin, and albumin. A mixed-effects meta-analysis was used to pool hazard ratios (HRs) from both cohorts to model mortality risk for each 10-unit increase in vitality. RESULTS: We used data from 4,285 PD patients (Brazil n = 1,388 and United States n = 2,897). Model estimates showed lower vitality levels within 90 days of starting PD were associated with a higher risk of mortality, which was consistent in Brazil and the United States cohorts. In the multivariate survival model, each 10-unit increase in vitality score was associated with lower risk of all-cause mortality in both cohorts (Brazil HR = 0.79 [95%CI 0.70 to 0.90] and United States HR = 0.90 [95%CI 0.88 to 0.93], pooled HR = 0.86 [95%CI 0.75 to 0.98]). Results for all models provided consistent effect estimates. CONCLUSIONS: Among patients in Brazil and the United States, lower vitality score in the initial months of PD was independently associated with all-cause mortality.

Women representation in academic and leadership positions in surgery in Brazil.

We aimed to analyze the representativeness of women surgeons in academic and leadership positions in Brazil. We investigated women representativeness across surgical departments of 25 Brazilian universities (2020); across boards of 10 Brazilian surgical societies (2020), and, as speakers, in 281 surgical events (Jan-2014 to Dec-2020). From 383 individuals in university departments, 43 (11.2 %) were women (p < 0.001). Only three universities had women as department chairs. From 163 positions in surgical societies, only 14 positions (8.6 %) were held by women (p < 0.001). The underrepresentation is worse in prestigious positions (presidency and vice-presidency), in which only 1 (5 %) were women. In 281 surgical events, there were 6686 speakers, of which only 886 (13.3 %) of these were women (p < 0.001). Further studies are needed to elucidate the possible causes for the gender gap in these scenarios in Brazil, so as to implement effective strategies to improve gender representativeness in surgery in the country.

Non-Governmental Organizations Delivering Global Cardiac Surgical Care: A Quantitative Impact Assessment.

In low- and middle-income countries (LMICs), 93% of the population lacks safe, timely, and affordable access to cardiac surgical care when needed. As countries slowly build or expand local, independent cardiac centers, non-governmental organizations (NGOs) partially bridge the gap in cardiac surgical care delivery in LMICs. However, little is known about the current scope of cardiac NGOs. Here, we perform an analysis of active NGOs involved with the delivery of cardiac surgical services in LMICs or for patients from LMICs. Cardiac surgery NGOs were identified from medical literature, established NGO databases, and Google Scholar searches. The search was performed between December 2019 and May 2020. NGOs whose websites were not updated or described missions or projects taking place no later than 2015 were considered inactive. Eighty-six NGOs are actively providing cardiac surgery services in LMICs or treating patients from LMICs. Five NGOs performed adult cardiac surgery only, 56 performed pediatric cardiac surgery only, and 25 performed both adult and pediatric cardiac surgery. NGOs originated from 23 different countries and were operational in a total of 111 countries, 96 of them being LMICs. Fifty-three NGOs reported data on annual surgical volume, of which half performed less than 50 operations per year. NGOs effectively address the burden of cardiac surgical disease in LMICs and contribute to local capacity-building. Increased, more detailed, and standardized reporting of the impact and outcomes of NGOs is necessary to better understand annual cardiac surgical volume and to support local centers working towards independent services.

Female and Country Representation on Editorial Boards of Cardiothoracic Surgery Journals.

Editorial board positions are prestigious and have important implications as gatekeepers for the advancement of academic surgeons. We assessed the composition of editorial boards of cardiothoracic surgery journals to identify female and low- and middle-income country (LMIC) representation. Journals listed as "Cardiac and Cardiovascular Systems" in the 2019 InCites Journal Citation Reports (JCR) directory by Clarivate Analytics were manually searched to identify journals pertaining to cardiothoracic surgery. Editorial boards for each journal were reviewed as available on journal websites, assessing for sex and country income group (high-income country vs. LMIC) of editorial board members. Descriptive statistics were performed, and differences were assessed through t tests and correlations using STATA version 14. Twenty-two cardiothoracic journals were identified, of which 16 were listed on JCR and 6 were sister journals. A total of 1,970 editorial board members were identified, of whom 206 (10.5%) were female and 103 (5.2%) from LMICs (each, p < 0.001). Female representation varied between 0% and 29.7% across journals. There were 391 associate and deputy editors, 62 (15.9%) were female and 15 (3.8%) from LMICs (each, p < 0.001). Only 1 (4.5%) of the 22 journals had a female Editor-in-Chief. A total of 15 LMICs were represented: Brazil (56 members), China (11 members), and India (11 members). LMIC representation varied between 0% and 76.6% (Brazilian Journal of Cardiovascular Surgery), with the second highest representation being only 16.33%. After excluding the Brazilian Journal of Cardiovascular Surgery (the only country-specific journal), LMIC representation was only 3.7% on editorial boards. The intersection between female sex and LMIC origin was found in only three editorial board members. A statistically significant positive correlation was seen between percentage of females in editorial boards and journal impact factor (r= 0.769, p < 0.001). No correlation was seen between percentage of LMIC in boards and impact factor (r = -0.306, p = 0.250). Our findings suggest editorial boards of cardiothoracic surgery journals remain highly imbalanced in terms of sex and country income group. Disparities in editorial boards may further result in less inclusive review processes, which may lead to fewer publications and slower academic advancement by underrepresented groups. Societies should partake in active assessment and reporting of disparities across their editorial boards as well as assessment of implicit biases and barriers impeding female and LMIC researchers from joining their boards.

Predictive Factors of Gastroesophageal Reflux Disease Symptoms Following Open Sleeve Gastrectomy in Brazil Using Clinical Questionnaire.

PURPOSE: To evaluate predictors of symptoms of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) based on a clinical questionnaire. MATERIALS AND METHODS: This is a cross-sectional study. We included all patients who underwent open SG between May 2013 and March 2017 in a single institution. Patients who could not be contacted or who did not want to participate were excluded. Clinical, demographic, and pre- and postoperative data were collected on medical records. Patients were contacted via telephone and inquired about GERD symptoms postoperatively. Symptoms were quantified using the GERD Questionnaire (GERDq). Patients were divided into three study groups according to GERDq score: asymptomatic (GERDq = 0), mildly symptomatic (GERDq ≤ 8), and severely symptomatic (GERDq > 8). Univariate analysis was performed using ANOVA, Kruskal-Wallis, Dunn, and chi-square tests. A logistic regression model was built for adjusted analysis of the data. RESULTS: One hundred eighty-nine patients were included. Mean age was 39.7 ± 10.71 years and 45.5% were female. Postoperative median follow-up period was 4.55 years (interquartile range 5.34-3.76). Mean GERDq score was 7.62 ± 10.17. Sixty-four patients were asymptomatic, 63 were mildly symptomatic, and 62 were severely symptomatic. The group of severely symptomatic patients showed a statistically lower preoperative weight when compared to the other groups (p = 0.049), but this association was not observed when analyzing preoperative BMI (p = 0.427). The other variables were not associated with postoperative GERD symptoms, both in univariate and adjusted analysis. CONCLUSION: No variables were statistically and clinically predictive of GERD occurrence or severity after SG. The pathophysiology of GERD is complex and further studies are needed to elucidate this condition.

Adult cardiac surgical cost variation around the world: Protocol for a systematic review.

INTRODUCTION: Globally, over one million cardiac operations occur each year, whereas cardiac surgery is expensive and largely inaccessible without insurance or philanthropic support. Substantial cost variation has been reported within cardiac surgery in the United States and among non-cardiac surgical procedures globally, but little is known on the global procedural cost variation for common adult cardiac surgical procedures. OBJECTIVES AND SIGNIFICANCE: This review seeks to assess variation in procedural costs of coronary artery bypass grafting (CABG), mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures between and within countries. Results may give insights in the scope and drivers of cost variation around the world, posing cost reduction lessons. Results may further inform the potential of economies of scale in reducing procedural costs, benefiting patients, hospitals, governments, and insurers. METHODS AND ANALYSIS: A systematic review will be performed using the EconLit, Embase, PubMed/MEDLINE, Web of Science, and WHO Global Index Medicus databases to identify articles published between January 1, 2000 and June 1, 2020. Studies describing procedural costs for CABG, mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures will be identified. Articles describing other types of cardiac surgery, concomitant aortic surgery, only describing costs related to non-surgical care, or with incomplete cost data will be excluded from the analysis. No exclusion will be based solely on article type or language. Identified costs will be converted to 2019 USD to account for local currency unit inflation and exchange fluctuations. ETHICS AND DISSEMINATION: This study protocol has been prospectively registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols. This review requires no institutional review board approval. Results of this study will be summarized and disseminated in a peer-review journal.

Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth?

BACKGROUND: Outcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability. METHODS: All adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years. RESULTS: Women were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21). CONCLUSIONS: Re-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.

Physical health-related quality of life at higher achieved hemoglobin levels among chronic kidney disease patients: a systematic review and meta-analysis.

BACKGROUND: The impact of anemia treatment with erythropoietin stimulating agents (ESA) on health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients is controversial, particularly regarding optimal hemoglobin (Hb) target ranges. METHODS: We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCT) with ESA to estimate the effect of different achieved Hb values on physical HRQOL and functionality. We searched PubMed, EMBASE, CENTRAL, PEDro, PsycINFO and Web of Science databases, until May 2020. Two authors independently extracted data from studies. We included observational and RCTs that enrolled CKD patients undergoing anemia treatment with ESA with different achieved Hb levels among groups. We excluded studies with achieved Hb < 9 g/dL. For the meta-analysis, we included RCTs with control groups achieving Hb 10-11.5 g/dL and active groups with Hb > 11.5 g/dL. We analyzed the standardized mean difference (SMD) between groups for physical HRQOL. RESULTS: Among 8496 studies, fifteen RCTs and five observational studies were included for the systematic review. We performed the meta-analysis in a subset of eleven eligible RCTs. For physical role and physical function, SMDs were 0.0875 [95% CI: - 0.0025 - 0.178] and 0.08 [95% CI: - 0.03 - 0.19], respectively. For fatigue, SMD was 0.16 [95% CI: 0.09-0.24]. Subgroup analysis showed that trials with greater achieved Hb had greater pooled effects sizes - 0.21 [95% CI: 0.07-0.36] for Hb > 13 g/dL vs. 0.09 [95% CI: 0.02-0.16] for Hb 11.5-13 g/dL. Proportion of older and long-term diabetic patients across studies were associated with lower effect sizes. CONCLUSION: Achieved hemoglobin higher than currently recommended targets may be associated with small but potentially clinically significant improvement in fatigue, but not in physical role or physical function. Younger and non-diabetic patients may experience more pronounced benefits of higher Hb levels after treatment with ESAs.

Surgical job negotiations: How current literature and expert opinion can inform your strategies.

BACKGROUND: Negotiation is an essential professional skill. Surgeons negotiating new roles must consider: 1) career level (e.g., new graduate, mid-career or leadership), 2) practice environment (e.g., academic, private practice), 3) organization (e.g., academic, university-affiliated, specialized center), and 4) work-life needs (e.g., geography, joint recruitment). METHODS: A review of the literature related to surgical job negotiation was conducted. Expert opinion was also sought. RESULTS: Current data and experience suggest that negotiation must be tailored to practice type, surgeon experience/skill set and should always occur with the advice of legal counsel. Understanding principled negotiation and engaging in preparation and practice will also improve negotiation skills. CONCLUSIONS: Our findings shed light on common blind spots among surgeons negotiating new professional roles and provide guidance on optimizing job negotiation skills.

Braden scale for pressure ulcer risk predicts rehabilitation placement after pancreatic resection.

BACKGROUND: Patients undergoing pancreatic resection frequently require rehabilitation facilities after hospital discharge. We evaluated the predictive role of validated markers of frailty on rehabilitation facility placement to identify patients who may require this service. METHODS: Single-center retrospective cohort study of patients who underwent pancreatic resection from 2010 to 2015. 90-day morbidity and mortality were calculated. Postoperative validated markers of frailty (Activities of Daily Living scale, Braden scale [assesses pressure ulcer risk, lower scores = higher risk] and Morse fall scale) were evaluated via multivariate regression to identify predictors of discharge to rehabilitation facility. RESULTS: 470 patients with complete data were included. Mean age was 62 and 49.2% were male. Postoperative median length of stay (LOS) was 8 (IQR 7-10). 92 (19.66%) patients were discharged to rehabilitation facilities and 138 (29.49%) patients were readmitted within 90 days. On multivariate analysis, age, sex, LOS > 8 days, inpatient Comprehensive Complication Index (CCI) and initial Braden scale were predictive of rehabilitation placement. CONCLUSION: A marker of frailty routinely collected daily by nursing staff, the Braden scale, is available to help surgeons predict the need for postoperative rehabilitation placement after pancreatic resection. Engaging discharge planning services for at-risk patients may help prevent delayed hospital discharge and should be further evaluated.

Greening the operating room.

BACKGROUND: Climate change will affect most populations in the next decades and put the health of billions of people at risk. Health care facilities represent a significant source of pollution around the world and contribute to environmental changes. To address this topic, we performed a review of the available literature on tactics to reduce operating room (OR) waste and the potential of these strategies to impact the environment. DATA SOURCES: A literature search was performed querying PubMed, Web of Science, and Science Direct. No comparative data were found; most were opinion papers, white papers, and case studies. For this reason, we proceeded with a narrative review, which provides an overview of the evidence on this topic and identifies areas for future research. RESULTS: This systematic review summarizes the available literature on the 5 "Rs" of waste management: reduction, reusing, recycling, rethinking, and renewable energies. CONCLUSIONS: Surgery has a unique opportunity to transition to more environmentally-friendly operating room strategies, which may help decrease waste and lessen the impact of climate change.