See One, Do One, Improve One's Wellness: Resident Autonomy in US General Surgery Programs, A Mixed-methods Study.

OBJECTIVE: We sought to examine the factors associated with resident perceptions of autonomy and to characterize the relationship between resident autonomy and wellness. BACKGROUND: Concerns exist that resident autonomy is decreasing, impacting competence. METHODS: Quantitative data were collected through a cross-sectional survey administered after the 2020 ABSITE. Qualitative data were collected through interviews and focus groups with residents and faculty at 15 programs. RESULTS: Seven thousand two hundred thirty-three residents (85.5% response rate) from 324 programs completed the survey. Of 5139 residents with complete data, 4424 (82.2%) reported appropriate autonomy, and these residents were less likely to experience burnout [odds ratio (OR) 0.69; 95% CI 0.58-0.83], suicidality (OR 0.69; 95% CI 0.54-0.89), and thoughts of leaving their programs (OR 0.45; 95% CI 0.37-0.54). Women were less likely to report appropriate autonomy (OR 0.81; 95% CI 0.68-0.97). Residents were more likely to report appropriate autonomy if they also reported satisfaction with their workload (OR 1.65; 95% CI 1.28-2.11), work-life balance (OR 2.01; 95% CI 1.57-2.58), faculty engagement (OR 3.55; 95% CI 2.86-4.35), resident camaraderie (OR 2.23; 95% CI, 1.78-2.79), and efficiency and resources (OR 2.37; 95% CI 1.95-2.88). Qualitative data revealed that (1) autonomy gives meaning to the clinical experience of residency, (2) multiple factors create barriers to autonomy, and (3) autonomy is not inherent to the training paradigm, requiring residents to learn behaviors to "earn" it. CONCLUSION: Autonomy is not considered an inherent part of the training paradigm such that residents can assume that they will achieve it. Resources to function autonomously should be allocated equitably to support all residents' educational growth and wellness.

Five-Year Prospective Observational Study of African-American Men on Active Surveillance for Prostate Cancer Demonstrates Race Is Not Predictive of Oncologic Outcomes.

INTRODUCTION: This study aimed to evaluate if race impacted outcomes or risk of disease progression in men on active surveillance (AS) for prostate cancer. We present the results from our majority African-American cohort of men in an equal access setting over a 5-year follow-up period. PATIENTS AND METHODS: All patients who elected AS for prostate cancer at the Southeast Louisiana Veterans Health Care System are entered into a prospectively managed observational database. Patients were divided into groups based on self-reported race. Grade group progression was defined as pathologic upgrading above International Society of Urological Pathology Grade Group 1 disease on subsequent biopsies following diagnostic biopsy. All tests were 2 sided using a significance of .05. RESULTS: A total of 228 men met inclusion criteria in the study, including 154 non-Hispanic African American and 74 non-Hispanic Caucasian American men, with a median follow-up of 5 years from the initiation of AS. Race was not predictive of Gleason grade progression, AS discontinuation, or biochemical recurrence on Cox multivariate analysis (HR = 1.01, 0.94, 0.85, P = .96, .79, .81, respectively). On Kaplan-Meier analysis at 5 years, African-American progression-free, AS discontinuation free, and overall survival probability was comparable to their Caucasian American counterparts (P > .05 for all). CONCLUSIONS: Active surveillance is a safe treatment option for low and very low risk prostate cancer, regardless of race. African-American and Caucasian-American men did not have any significant difference in Gleason grade group progression in our cohort with 5-year follow-up.

The case for a new post-graduate hernia designation: a review of fellowship council case logs from the past twelve-years.

BACKGROUND: The Fellowship Council (FC) is a robust accreditation body with numerous fellowships; however, no specific criteria exist for hernia fellowships. This study analyzed the case log database to evaluate trends in fellowship exposure to hernia repairs. METHODS: FC hernia case log records (2007-2019) were coded as inguinal or ventral hernias and with or without mesh repair. Retrospective analysis examined total hernia repairs logged, type of repair, program designation, and robotic adoption. Robotic adoption was categorized by quartiles of program performance according to the final year of analysis (2018-2019); yearly performance was then graphed by quartiles. RESULTS: Over this twelve-year period, 93,334 hernia repairs, 5 program designations, 152 unique programs and 1,558 unique fellows were analyzed. The number of fellows grew from 106 (2007-2008) to > 130 (2018-2019). Total hernias repairs per fellow increased from an average of 41.2 in 2007-2008 to 75.7 in 2018-2019 (183.7%). Open and robotic hernia repairs increased by 241.9% and 266.3%, respectively; laparoscopic hernia repairs decreased by 14.8%. Inguinal and ventral hernia repairs comprised 48.1% and 51.9% of total cases, respectively. Advanced GI/MIS and Advanced GI/MIS/Bariatrics programs logged the majority of hernia repairs (86.0-90.2%). 2014 began an exponential rise in robotic adoption, with fellows averaging < 1 robotic repairs before and > 25 repairs in 2019. A significant difference was found between all groups when comparing quartiles of robotic adopters (median robotic repairs per fellow; IQR): first quartile (72.0; 47.9-108.8), second quartile (25.5; 21.0-30.6), third quartile (13.0; 12.0-14.3) and fourth quartile (3.5; 0.5-5.0) (p-value < 0.05). CONCLUSIONS: This twelve-year analysis shows a near doubling in the growth of total hernia repairs, with a decrease in laparoscopic repairs as robotic repairs increased. These data show the importance of hernia repairs in FC fellows' training and warrant further granular analysis to determine specific accreditation criteria for hernia fellowship designations.

Less is more: single dose versus extended antibiotic prophylaxis for transperineal prostate biopsy.

INTRODUCTION: There is an ongoing debate as to the appropriate regimen of antibiotic prophylaxis with transperineal (TP) biopsy. The objective of this study was to report the rate of infection following TP biopsy at a high-volume institution and assess the impact of single dose antibiotics at the time of biopsy versus outpatient antibiotics in preventing postprocedural infections. MATERIALS AND METHODS: Records of men undergoing TP prostate biopsy from 2012 to 2022 were reviewed. Patients were divided into two groups, those who received single dose intravenous (IV) antibiotics at the time of biopsy (n = 440) and those who received both IV antibiotics at the time of biopsy and outpatient antibiotics before/after biopsy (n = 327). Post biopsy infection was defined as at least one of the following: fever (≥ 38.3°C) with/without symptoms of urinary tract infection or positive urine culture (> 105 colony forming units) within 72 hours post biopsy. The rates of infection were compared between the two groups. RESULTS: A total of 767 biopsies were included in the study. Infection rate post TP biopsy was 1.83% (n = 14). The infection rate for patients with single dose prophylaxis was 2.05% (n = 9) and 1.53% (n = 5) for those that received the extended antibiotic regimen. No significant difference in infection rates between the different antibiotic regimens was found (p = 0.597). CONCLUSIONS: Overall rates of infection after TP prostate biopsy are very low. Our data indicate that single dose and extended regimen of antibiotic prophylaxis show similar infection rates. These findings support antibiotic stewardship and encourage further research into the appropriate regimen of prophylaxis for TP prostate biopsy.

Feasibility of postoperative diffusion-weighted imaging to assess representations of spinal cord microstructure in cervical spondylotic myelopathy.

OBJECTIVE: Diffusion basis spectrum imaging (DBSI) has shown promise in evaluating cervical spinal cord structural changes in patients with cervical spondylotic myelopathy (CSM). DBSI may also be valuable in the postoperative setting by serially tracking spinal cord microstructural changes following decompressive cervical spine surgery. Currently, there is a paucity of studies investigating this topic, likely because of challenges in resolving signal distortions from spinal instrumentation. Therefore, the objective of this study was to assess the feasibility of DBSI metrics extracted from the C3 spinal level to evaluate CSM patients postoperatively. METHODS: Fifty CSM patients and 20 healthy controls were enrolled in a single-center prospective study between 2018 and 2020. All patients and healthy controls underwent preoperative and postoperative diffusion-weighted MRI (dMRI) at a 2-year follow-up. All CSM patients underwent decompressive cervical surgery. The modified Japanese Orthopaedic Association (mJOA) score was used to categorize CSM patients as having mild, moderate, or severe myelopathy. DBSI metrics were extracted from the C3 spinal cord level to minimize image artifact and reduce partial volume effects. DBSI anisotropic tensors evaluated white matter tracts through fractional anisotropy, axial diffusivity, radial diffusivity, and fiber fraction. DBSI isotropic tensors assessed extra-axonal pathology through restricted and nonrestricted fractions. RESULTS: Of the 50 CSM patients, both baseline and postoperative dMR images with sufficient quality for analysis were obtained in 27 patients. These included 15 patients with mild CSM (mJOA scores 15-17), 7 with moderate CSM (scores 12-14), and 5 with severe CSM (scores 0-11), who were followed up for a mean of 23.5 (SD 4.1, range 11-31) months. All preoperative C3-level DBSI measures were significantly different between CSM patients and healthy controls (p < 0.05), except DBSI fractional anisotropy (p = 0.31). At the 2-year follow-up, the same significance pattern was found between CSM patients and healthy controls, except DBSI radial diffusivity was no longer statistically significant (p = 0.75). When assessing change (i.e., postoperative - preoperative values) in C3-level DBSI measures, CSM patients exhibited significant decreases in DBSI radial diffusivity (p = 0.02), suggesting improvement in myelin integrity (i.e., remyelination) at the 2-year follow-up. Among healthy controls, there was no significant difference in DBSI metrics over time. CONCLUSIONS: DBSI metrics derived from dMRI at the C3 spinal level can be used to provide meaningful insights into representations of the spinal cord microstructure of CSM patients at baseline and 2-year follow-up. DBSI may have the potential to characterize white matter tract recovery and inform outcomes following decompressive cervical surgery for CSM.

Clomiphene Citrate in the Management of Infertility in Oligospermic Obese Men with Hypogonadism: Retrospective Pilot Study.

Background and Objectives: Obesity is a significant risk factor for hypogonadism and infertility that is further associated with reduced semen quality. The aim of this study is to evaluate the effect of clomiphene citrate (CC), prescribed for treating infertility, on serum testosterone and semen parameters, particularly in oligospermic obese hypogonadal men. Materials and Methods: A retrospective analysis of data related to men (n = 53) who underwent CC treatment for infertility and hypogonadism (testosterone < 300 ng/dL) was performed. Patients with obesity (BMI ≥ 30 kg/m2) and sperm concentration ≤ 15 × 106/mL were included for analysis. Results: The overall results showed that, in oligospermic obese men (n = 31), treatment with CC significantly improved baseline sperm concentration (4.5 ± 6.8 × 106/mL vs. 11.4 ± 15.5 × 106/mL, p < 0.05) and motility (31.5% ± 21.5% vs. 42.6% ± 14.7%, p < 0.05). Furthermore, subsequent examination of oligospermic hypogonadal obese men treated with CC (n = 13) revealed substantial improvements in baseline serum testosterone levels (193.8 ± 59.3 ng/dL vs. 332.7 ± 114.8 ng/dL, p < 0.05) along with an increase in sperm concentration, total motility, and normal morphology. Conclusions: The results of this retrospective study suggest that CC treatment not only improves chances of fertility outcomes by substantially improving semen parameters but also increases total serum testosterone levels in oligospermic obese men without any supplemental and expensive testosterone replacement therapy.

Gender Differences in Entrustable Professional Activity Evaluations of General Surgery Residents.

OBJECTIVE: To determine differences in entrustable professional activity (EPA) assessments between male and female general surgery residents. SUMMARY BACKGROUND DATA: Evaluations play a critical role in career advancement for physicians. However, female physicians in training receive lower evaluations and underrate their own performance. Competency-based assessment frameworks, such as EPAs, may help address gender bias in surgery by linking evaluations to specific, observable behaviors. METHODS: In this cohort study, EPA assessments were collected from July 2018 to May 2020. The effect of resident sex on EPA entrustment levels was analyzed using multiple linear and ordered logistic regressions. Narrative comments were analyzed using latent dirichlet allocation to identify topics correlated with resident sex. RESULTS: Of the 2480 EPAs, 1230 EPAs were submitted by faculty and 1250 were submitted by residents. After controlling for confounding factors, faculty evaluations of residents were not impacted by resident sex (estimate = 0.09, P = 0.08). However, female residents rated themselves lower by 0.29 (on a 0-4 scale) compared to their male counterparts (P < 0.001). Within narrative assessments, topics associated with resident sex demonstrated that female residents focus on the "guidance" and "supervision" they received while performing an EPA, while male residents were more likely to report "independent" action. CONCLUSIONS: Faculty assessments showed no difference in EPA levels between male and female residents. Female residents rate themselves lower by nearly an entire post graduate year (PGY) level compared to male residents. Latent dirichlet allocation -identified topics suggest this difference in self-assessment is related to differences in perception of autonomy.

Lack of association of post-discharge prophylactic antibiotics with decreased risk of surgical site infection following spinal fusion.

OBJECTIVES: To determine the prevalence and factors associated with post-discharge prophylactic antibiotic use after spinal fusion and whether use was associated with decreased risk of surgical site infection (SSI). METHODS: Persons aged 10-64 years undergoing spinal fusion between 1 January 2010 and 30 June 2015 were identified in the MarketScan Commercial Database. Complicated patients and those coded for infection from 30 days before to 2 days after the surgical admission were excluded. Outpatient oral antibiotics were identified within 2 days of surgical discharge. SSI was defined using ICD-9-CM diagnosis codes within 90 days of surgery. Generalized linear models were used to determine factors associated with post-discharge prophylactic antibiotic use and with SSI. RESULTS: The cohort included 156 446 fusion procedures, with post-discharge prophylactic antibiotics used in 9223 (5.9%) surgeries. SSIs occurred after 2557 (1.6%) procedures. Factors significantly associated with post-discharge prophylactic antibiotics included history of lymphoma, diabetes, 3-7 versus 1-2 vertebral levels fused, and non-infectious postoperative complications. In multivariable analysis, post-discharge prophylactic antibiotic use was not associated with SSI risk after spinal fusion (relative risk 0.98; 95% CI 0.84-1.14). CONCLUSIONS: Post-discharge prophylactic oral antibiotics after spinal fusion were used more commonly in patients with major medical comorbidities, more complex surgeries and those with postoperative complications during the surgical admission. After adjusting for surgical complexity and infection risk factors, post-discharge prophylactic antibiotic use was not associated with decreased SSI risk. These results suggest that prolonged prophylactic antibiotic use should be avoided after spine surgery, given the lack of benefit and potential for harm.

Antireflux surgery leads to durable improvement in laryngopharyngeal reflux symptoms.

BACKGROUND: Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery. METHODS: Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2 weeks, 8 weeks, and 1 year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and > 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores. RESULTS: One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8 years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI > 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p > 0.05). The RSI > 13 group had more female patients (80 vs 52%, p = < 0.001), higher mean GERD-HRQL score, lower rates of PPI use, and normal esophageal motility. The RSI of all patients improved from a mean preoperative value of 19.2 to 7.8 (2 weeks), 6.1 (8 weeks), and 10.9 (1 year). Those with the highest preoperative scores (RSI > 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking. CONCLUSIONS: In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.

Comparison of the Perspectives of Medical Students and Residents on the Surgery Learning Environment.

BACKGROUND: The learning environment plays a critical role in learners' satisfaction and outcomes. However, we often lack insight into learners' perceptions and assessments of these environments. It can be difficult to discern learners' expectations, making their input critical. When medical students and surgery residents are asked to evaluate their teachers, what do they focus on? MATERIALS AND METHODS: Open-ended comments from medical students' evaluations of residents and attending surgeons and from residents' evaluations of attendings during the 2016-2017 academic year were analyzed. Content analysis was used, and codes derived from the data. A matrix of theme by learner role was created to distinguish differences between medical student and resident learners. Subthemes were grouped based on similarity into high-order themes. RESULTS: Two overarching themes were Creating a positive environment for learning by modeling professional behaviors and Intentionally engaging learners in training and educational opportunities. Medical students and residents made similar comments for the subthemes of appropriate demeanor, tone and dialog, respect, effective direct instruction, feedback, debriefing, giving appropriate levels of autonomy, and their expectations as team members on a service. Differences existed in the subthemes of punctuality, using evidence, clinical knowledge, efficiency, direct interactions with patients, learning outcomes, and career decisions. CONCLUSIONS: Faculty development efforts should target professional communication, execution of teaching skills, and relationships among surgeons, other providers, and patients. Attendings should make efforts to discuss their approach to clinical decision making and patient interactions and help residents and medical students voice their opinions and questions through trusting adult learner-teacher relationships.

At-home hands-on surgical training during COVID19: proof of concept using a virtual telementoring platform.

INTRODUCTION: Surgeons in practice have limited opportunities to learn new techniques and procedures. Traditionally, in-person hands-on courses have been the most common means for surgeons to gain exposure to new techniques and procedures. The COVID19 pandemic caused a cessation in these courses and left surgeons with limited opportunities to continue their professional development. Thus, SAGES elected to create an innovative hands-on course that could be completed at home in order to provide surgeons with opportunities to learn new procedures during the pandemic. METHODS: This course was initially planned to be taught as an in-person hands-on course utilizing the Acquisition of Data for Outcomes and Procedure Transfer(ADOPT) method 1. We identified a virtual telementoring platform, Proximie Ltd(London, UK), and a company that could create a model of an abdominal wall in order to perform a Transversus Abdominis Release, KindHeart™(Chapel Hill, NC, USA). The course consisted of pre-course lectures and videos to be reviewed by participants, a pre-course call to set learning goals, the hands-on telementoring session from home, and monthly webinars for a year. RESULTS: The ADOPT hands-on hernia course at home was successfully completed on October 23rd of 2020. All participants and faculty were successfully able to set up their model and utilize the telementoring platform, but 15% required assistance. Post course-surveys showed that participants felt that the course was successful in meeting their educational goals and felt similar to prior in-person courses. CONCLUSIONS: SAGES was successfully able to transition and in-person hands-on course to a virtual at-home format. This innovative approach to continuing professional development will be necessary during the times of the COVID19 pandemic, but may be a helpful option for rural surgeons and others with travel restrictions in the future to continue their professional development without the need to travel away from their practice.

Phone follow-up after inguinal hernia repair.

BACKGROUND: Typically, in-person follow-up in clinic is utilized after outpatient inguinal hernia repair. Studies have shown that phone follow-up may be successfully used for the detection of postoperative hernia recurrences. However, no studies have evaluated the detection rates of other postoperative complications, such as emergency department visits and readmissions, with the utilization of phone follow-up after inguinal hernia repair. The objective of our study was to investigate the safety of a phone follow-up care pathway following elective, outpatient inguinal hernia repair. METHODS: In this retrospective cohort study, adult patients who underwent elective, outpatient inguinal hernia repair between 2013 and 2019 at a large academic health system in the Midwest United States were identified from the electronic health record. Patients were categorized by type of postoperative follow-up: in-person or phone follow-up. Baseline demographics, operative, and postoperative data were compared between follow-up groups. Multivariable logistic regression was performed to investigate predictors of having any related emergency department (ED) visit/readmission/reoperation within 90 days. RESULTS: We included 2009 patients who underwent elective inguinal hernia repair during the study period. 321 patients had in-person follow-up only, while 1,688 patients had phone follow-up. There was a higher rate of laparoscopic repair in the phone follow-up group (85.4% vs. 53.0% for in-person follow-up). There were no differences in rates of related 90-day ED visits, readmissions, and reoperations between the phone and in-person follow-up groups. On multivariable logistic regression, receipt of phone follow-up was not a predictor of having 90-day ED visits, readmissions, or reoperations (OR 1.30, 95% CI [0.83, 2.05]). CONCLUSIONS: Patients who underwent phone follow-up had similarly low rates of adverse outcomes to those with in-person follow-up. Phone follow-up protocols may be implemented as an alternative for patients and provide a means to decrease healthcare utilization following inguinal hernia repair.

Unnecessary use of radiology studies in the diagnosis of inguinal hernias: a retrospective cohort study.

BACKGROUND: The diagnosis of inguinal hernias is predominantly based on physical exam, although imaging may be used in select cases. The objective of this study was to determine the frequency of unnecessary imaging used in the diagnosis of inguinal hernias. METHODS: Patients who underwent elective inguinal hernia repair at a large academic health system in the U.S. from 2010 to 2017 were included. Within this cohort, we identified patients who received imaging 6 months prior to surgery. Through chart review of physical exam findings and imaging indications, we categorized patients into four imaging categories: unrelated, necessary, unnecessary, and borderline. Multivariable logistic regression analysis was used to identify factors associated with receipt of unnecessary imaging. RESULTS: Of 2162 patients who underwent inguinal hernia surgery, 249 patients had related imaging studies 6 months prior to surgery. 47.0% of patients received unnecessary imaging. 66.9% and 33.1% of unnecessary studies were ultrasounds and CT scans, respectively. 24.5% of patients had necessary studies, while 28.5% had studies with borderline indications. On multivariable analysis, having a BMI between 25.0 and 29.9 kg/m2 was associated with receipt of unnecessary studies. Primary care providers and ED physicians were more likely to order unnecessary imaging. CONCLUSIONS: Nearly 50% of all patients who receive any related imaging prior to surgery had potentially unnecessary diagnostic radiology studies. This not only exposes patients to avoidable risks, but also places a significant economic burden on patients and our already-strained health system.

Ultrasound-guided microwave ablation in the treatment of inguinal neuralgia.

Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.

Electronic clinical decision support for children with minor head trauma and intracranial injuries: a sociotechnical analysis.

BACKGROUND: Current management of children with minor head trauma (MHT) and intracranial injuries is not evidence-based and may place some children at risk of harm. Evidence-based electronic clinical decision support (CDS) for management of these children may improve patient safety and decrease resource use. To guide these efforts, we evaluated the sociotechnical environment impacting the implementation of electronic CDS, including workflow and communication, institutional culture, and hardware and software infrastructure, among other factors. METHODS: Between March and May, 2020 semi-structured qualitative focus group interviews were conducted to identify sociotechnical influences on CDS implementation. Physicians from neurosurgery, emergency medicine, critical care, and pediatric general surgery were included, along with information technology specialists. Participants were recruited from nine health centers in the United States. Focus group transcripts were coded and analyzed using thematic analysis. The final themes were then cross-referenced with previously defined sociotechnical dimensions. RESULTS: We included 28 physicians and four information technology specialists in seven focus groups (median five participants per group). Five physicians were trainees and 10 had administrative leadership positions. Through inductive thematic analysis, we identified five primary themes: (1) clinical impact; (2) stakeholders and users; (3) tool content; (4) clinical practice integration; and (5) post-implementation evaluation measures. Participants generally supported using CDS to determine an appropriate level-of-care for these children. However, some had mixed feelings regarding how the tool could best be used by different specialties (e.g. use by neurosurgeons versus non-neurosurgeons). Feedback from the interviews helped refine the tool content and also highlighted potential technical and workflow barriers to address prior to implementation. CONCLUSIONS: We identified key factors impacting the implementation of electronic CDS for children with MHT and intracranial injuries. These results have informed our implementation strategy and may also serve as a template for future efforts to implement health information technology in a multidisciplinary, emergency setting.

Prospective comparison of longitudinal change in hepatic proton density fat fraction (PDFF) estimated by magnitude-based MRI (MRI-M) and complex-based MRI (MRI-C).

PURPOSE: To compare longitudinal hepatic proton density fat fraction (PDFF) changes estimated by magnitude- vs. complex-based chemical-shift-encoded MRI during a weight loss surgery (WLS) program in severely obese adults with biopsy-proven nonalcoholic fatty liver disease (NAFLD). METHODS: This was a secondary analysis of a prospective dual-center longitudinal study of 54 adults (44 women; mean age 52 years; range 27-70 years) with obesity, biopsy-proven NAFLD, and baseline PDFF ≥ 5%, enrolled in a WLS program. PDFF was estimated by confounder-corrected chemical-shift-encoded MRI using magnitude (MRI-M)- and complex (MRI-C)-based techniques at baseline (visit 1), after a 2- to 4-week very low-calorie diet (visit 2), and at 1, 3, and 6 months (visits 3 to 5) after surgery. At each visit, PDFF values estimated by MRI-M and MRI-C were compared by a paired t test. Rates of PDFF change estimated by MRI-M and MRI-C for visits 1 to 3, and for visits 3 to 5 were assessed by Bland-Altman analysis and intraclass correlation coefficients (ICCs). RESULTS: MRI-M PDFF estimates were lower by 0.5-0.7% compared with those of MRI-C at all visits (p < 0.001). There was high agreement and no difference between PDFF change rates estimated by MRI-M vs. MRI-C for visits 1 to 3 (ICC 0.983, 95% CI 0.971, 0.99; bias = - 0.13%, p = 0.22), or visits 3 to 5 (ICC 0.956, 95% CI 0.919-0.977%; bias = 0.03%, p = 0.36). CONCLUSION: Although MRI-M underestimates PDFF compared with MRI-C cross-sectionally, this bias is consistent and MRI-M and MRI-C agree in estimating the rate of hepatic PDFF change longitudinally. KEY POINTS: • MRI-M demonstrates a significant but small and consistent bias (0.5-0.7%; p < 0.001) towards underestimation of PDFF compared with MRI-C at 3 T. • Rates of PDFF change estimated by MRI-M and MRI-C agree closely (ICC 0.96-0.98) in adults with severe obesity and biopsy- proven NAFLD enrolled in a weight loss surgery program. • Our findings support the use of either MRI technique (MRI-M or MRI-C) for clinical care or by individual sites or for multi-center trials that include PDFF change as an endpoint. However, since there is a bias in their measurements, the same technique should be used in any given patient for longitudinal follow-up.

Surgical Trainees' Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal.

BACKGROUND: Surgeon educators express concern about trainees' sense of patient ownership. We aimed to compare resident and faculty perceptions on residents' sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics. METHODS: An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at seven academic surgery residencies across the United States. We modified an established psychological ownership scale to measure patient ownership among surgical trainees. RESULTS: Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 78.0% of faculty agreed that residents took personal responsibility for patient outcomes, but only 26.4% thought residents felt a similar or higher degree of patient ownership compared with themselves. Faculty underestimated the proportion of residents that routinely checked on their patients when off-duty (36.8 versus 92.6%, P < 0.001). Higher means on the patient ownership scale correlated with female sex (5.9 versus. 5.5 for males, P = 0.009), advanced post graduate year level (5.3, 5.5, 5.7, 5.8, 6.1, for post graduate year 1-5, respectively, P = 0.02), and the sense that patient outcomes affected the resident respondent's mood (5.8 versus 4.8 for those whose mood was not affected, P < 0.001). In addition, trainees who perceived better resident camaraderie (P = 0.004), faculty mentorship (P < 0.001), and that their program provided appropriate autonomy (P = 0.03) felt greater responsibility for patient outcomes. CONCLUSIONS: Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents' sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.

Hematologic parameters are not predictors of upgrading or treatment in a racially diverse prospective study of men with prostate cancer on active surveillance.

INTRODUCTION: Neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte ratios (PLR) are useful clinical biomarkers for prognosis in several malignancies. Their predictive value has been less clearly demonstrated with prostate cancer (PCa), particularly, their utility within active surveillance (AS) protocols. We aim to evaluate NLR and PLR in AS patients. METHODS: We identified 98 patients who met inclusion criteria in our cohort of 274 men diagnosed with PCa on AS. Patients were then categorized into high and low NLR and PLR groups. RESULTS: The 2.5 and 5-year Gleason upgrading free probability for our high NLR cohort was 73.9%(CI 56.3% to 97.0%) and 46.2%(CI 22.4% to 95.1%) compared to 76.3%(CI 65.7% to 88.7%) and 61.7%(CI 47.7% to 80.0%) in the low NLR cohort(p = .73). The 2.5 and 5-year Gleason upgrading free probability for our High PLR cohort was 73.5%(CI 57.3% to 94.2%) and 60.1(CI 41.4% to 87.4%) compared to 76.8%(CI 65.8% to 89.65) and 58.1%(CI 42.2% to 80.1%) in our low PLR group(p = .41). A multivariant analysis demonstrated these groups were not significant predictors of upgrading or treatment. CONCLUSION: Despite their usefulness in many types of malignancy, NLR and PLR were not predictors of upgrading or treatment in men on AS for localized PCa in our cohort.

Propargylglycine-based antimicrobial compounds are targets of TolC-dependent efflux systems in Escherichia coli.

A library of novel l-propargylglycine-based compounds were designed and synthesized with the goal of inhibiting the growth of Gram-negative bacteria by targeting LpxC, a highly conserved Gram-negative enzyme which performs an essential step in the lipid A biosynthetic pathway. These compounds were designed with and without a nucleoside and had varying tail structures, which modulate their lipophilicity. The synthetic scheme was improved compared to previous methods: a methyl ester intermediate was converted to a hydroxamic acid, which obviated the need for a THP protecting group and improved the yields and purity of the final compounds. Antimicrobial activity was observed for non-nucleoside compounds containing a phenyl propargyl ether tail (5) or a biphenyl tail (6). An MIC of 16 µg/mL was achieved for 6 in Escherichia coli, but inhibition was only possible in the absence of TolC-mediated efflux. Compound 5 had an initial MIC >160 µg/mL in E. coli. Enhancing outer membrane permeability or eliminating efflux reduced the MIC modestly to 100 µg/mL and 80 µg/mL, respectively. These results highlight the importance of hydrophobicity of this class of compounds in developing LpxC inhibitors, as well as the design challenge of avoiding multidrug efflux activity.

Long-term dysphagia resolution following POEM versus Heller myotomy for achalasia patients.

BACKGROUND: Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period. METHODS: Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome. RESULTS: Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes. CONCLUSIONS: POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.