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The purpose of this editorial is to illustrate how the Operative Standards for Cancer Surgery can be used as a tool to support education of surgical trainees. The three-volume text is a valuable resource not only for learning the scientific principles related to surgical oncology, but also as a technical guide for critical aspects of performing operations and a primer for quality assurance going forward in a surgical career., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Since 2013, we have offered a robust "Introduction to Surgery" elective (ITS) for preclinical medical students. The present study investigates whether participants of the ITS elective were more likely to match into surgical residencies than non-ITS participants., Methods: This is a retrospective case-control study of medical students from two medical schools in Southern California who participated in the ITS elective and those who did not. Descriptive results and univariate analysis using STATA were utilized to analyze the de-identified data who matched between 2016 and 2021 were included., Results: Overall, 87 (8.9%) of the 982 matched students participated in the ITS elective, with an increase in participation from 1.2% in 2016 to 13.9% in 2021 ( P < .001). Among ITS participants, 49.4% matched into a surgical specialty compared to only 22.9% for non-ITS students ( P < .001). There was no difference between ITS and non-ITS students with regards to procedural specialty match (14.9% vs 12.6%, P = .537)., Conclusion: ITS participants were more than twice as likely to match into a surgical specialty than non-participants. Future qualitative research will help discern the relative impact of the ITS course versus a student's baseline predisposition to surgery.

Background: Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome., Methods: The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center., Results: Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization., Conclusion: We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: The wellbeing of sexual and gender minority (SGM) medical students and the impact of their experiences on career trajectory remain poorly understood. The present study aimed to characterize the incidence of mistreatment in SGM trainees as well as general perspectives on the acceptance of SGM individuals across medical and surgical specialties., Methods: This was a cross sectional survey study of all actively enrolled medical students within the six University of California campuses conducted in March 2021. An online, survey tool captured incidence of bullying, discrimination, and suicidal ideation as well as perceived acceptance of SGM identities across specialties measured by slider scale. Differences between SGM and non-SGM respondents were assessed with two-tailed and chi-square tests. Qualitative responses were evaluated utilizing a multi-stage, cutting-and-sorting technique., Results: Of approximately 3,205 students eligible for participation, 383 submitted completed surveys, representing a response rate of 12.0%. Of these respondents, 26.9% (n = 103) identified as a sexual or gender minority. Overall, SGM trainees reported higher slider scale scores when asked about being bullied by other students (20.0 vs. 13.9, P = 0.012) and contemplating suicide (14.8 vs. 8.8, P = 0.005). Compared to all other specialties, general surgery and surgical subspecialties had the lowest mean slider scale score (52.8) in perceived acceptance of SGM identities (All P < 0.001). In qualitative responses, students frequently cited lack of diversity as contributing to this perception. Additionally, 67.0% of SGM students had concerns that disclosure of identity would affect their future career with 18.5% planning to not disclose during the residency application process., Conclusions: Overall, SGM respondents reported higher incidences of bullying and suicidal ideation as well as increased self-censorship stemming from concerns regarding career advancement, most prominently in surgery. To address such barriers, institutions must actively promote diversity in sexual preference and gender identity regardless of specialty., Competing Interests: The authors have declared that no competing interests exist.

Background: High hospital safety-net burden has been associated with inferior clinical outcomes. We aimed to characterize the association of safety-net burden with outcomes in a national cohort of patients undergoing carotid interventions., Methods: The 2010-2017 Nationwide Readmissions Database was used to identify adults undergoing carotid endarterectomy and carotid artery stenting. Hospitals were classified as low (LBH), medium, or high safety-net burden (HBH) based on the proportion of uninsured or Medicaid patients. Multivariable models were developed to evaluate associations between HBH and outcomes., Results: Of an estimated 540,558 hospitalizations for a carotid intervention, 28.5% were at HBH. Patients treated at HBH were more likely to be admitted non-electively (28.7% vs 20.2%, P < .001), have symptomatic presentation (11.0% vs 7.7%, P < .001), and undergo carotid artery stenting (18.7% vs 8.9%, P < .001). After adjustment, HBH remained associated with increased odds of postoperative stroke (AOR 1.19, P = .023, Ref = LBH), non-home discharge (AOR 1.10, P = .026), 30-day readmissions (AOR 1.14, P < .001), and 31-90-day readmissions (AOR 1.13, P < .001), but not in-hospital mortality (AOR 1.18, P = .27). HBH was linked to increased hospitalization costs (β +$2,169, P = .016)., Conclusion: HBH was associated with postoperative stroke, non-home discharge, readmissions, and increased hospitalization costs after carotid revascularization. Further studies are warranted to alleviate healthcare inequality and improve outcomes at safety-net hospitals., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Although socioeconomic disparities persist both pre- and post-transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States. All adults (age ≥18 years) listed for LT between 2002 and 2018 in the United Network for Organ Sharing database were included. The primary outcome was waitlist removal because of death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal-Wallis and chi-square tests, respectively. Fine and Gray competing-risks regression was used to estimate the subdistribution hazard ratios (HRs) for risk factors associated with delisting. Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare, and 15.9% by Medicaid. The 1-year cumulative incidence of delisting was 9.0% (95% confidence interval [CI], 8.3%-9.8%) for patients with private insurance, 10.7% (95% CI, 9.9%-11.6%) for Medicare, and 10.7% (95% CI, 9.8%-11.6%) for Medicaid. In multivariable competing-risks analysis, Medicare (HR, 1.20; 95% CI, 1.17-1.24; P < 0.001) and Medicaid (HR, 1.20; 95% CI, 1.16-1.24; P < 0.001) were independently associated with an increased hazard of death or deterioration compared with private insurance. Additional predictors of delisting included Black race and Hispanic ethnicity, whereas college education and employment were associated with a decreased hazard of delisting. In this study, LT candidates with Medicare or Medicaid had a 20% increased risk of delisting because of death or clinical deterioration compared with those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population., (Copyright © 2020 by the American Association for the Study of Liver Diseases.)

Background: Reducing inpatient readmissions is a national priority for improving healthcare quality and decreasing costs. Previous studies have shown that readmissions after surgical aortic valve replacement are frequent and contribute to increased healthcare costs, yet no studies have analyzed risk factors for readmission., Methods: The Nationwide Readmissions Database was used to identify adult patients undergoing surgical aortic valve replacement from 2010 to 2015. Incidence, patient characteristics, causes, resource utilization, and predictors of 30-day readmission were determined. International Classification of Diseases codes were used to capture surgical aortic valve replacement., Results: Among 136,051 patients, 18,631 (13.7%) were readmitted within 30 days of discharge. Readmitted patients were more commonly women (47.4% vs 41.6%; P < .001) and were older (70.4 years of age vs 68.3 years of age; P < .001), with higher Elixhauser comorbidity index (5.4 vs 4.8; P < .001), rates of postoperative complications (44.0% vs 37.3%; P < .001), and greater length of stay (10.9 days vs 8.5 days; P < .001). The mean cost of 1 readmission episode was $13,426. On multivariable analysis, significant predictors of readmission were female sex, age greater than 75 years, atrial fibrillation, chronic kidney and liver disease, and lower surgical aortic valve replacement hospital volume. A total of 49.1% of readmissions were related to cardiac causes, with heart failure (13.2%) and arrhythmia (12.5%) being the most common., Conclusions: Using a national inpatient database, we found readmission after surgical aortic valve replacement to be common and resource-intensive. Enhanced management of comorbidities and targeted postdischarge interventions for patients at high risk of readmission may help decrease healthcare utilization., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Deep venous thrombosis and pulmonary embolism are life-threatening complications after surgery, warranting prophylaxis. However prophylaxis is not uniformly practiced among cardiac surgical patients. This study aimed to characterize the national incidence, mortality, and costs associated with thromboembolism after cardiac surgery., Methods: The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing coronary artery bypass grafting or valve surgery. International Classification of Disease codes were used to identify patients with deep venous thrombosis and pulmonary embolism., Results: Of approximately 3 million patients undergoing cardiac surgery, 1.62% developed deep venous thrombosis and 0.38% pulmonary embolism. Those with deep venous thrombosis and pulmonary embolism were more commonly women (33.2% and 36.2 vs 31.2%, P < .001), older (68.1 and 66.0% vs 65.7 years, P < .001), and had a higher Elixhauser comorbidity index (4.0 and 4.7 vs 3.7, P < .001). Deep venous thrombosis and pulmonary embolism were associated with increased mortality (4.95% and 14.8% vs 2.67%, P < .001). After adjustment for baseline differences, deep venous thrombosis was associated with an incremental increase in cost of $12,308, whereas pulmonary embolism was associated with $13,879 cost increase after cardiac surgery. Pulmonary embolism was an independent predictor of mortality (adjusted odds ratio, 3.39; 95% confidence interval, 2.74-4.18)., Conclusions: The mortality and financial burden related to thromboembolism in cardiac surgery are significant. Prophylaxis may be indicated in cardiac surgery patients to improve quality of care and reduce healthcare costs. Future controlled randomized trials investigating the benefit of thromboembolism prophylaxis in cardiac surgery are warranted., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, complications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospitalizations. The malnourished cohort included patients with nutritional neglect, cachexia, protein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected outcomes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experienced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a significant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preoperative risk stratification and malnutrition modification may improve outcomes in this vulnerable population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy., Methods: The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission., Results: Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively., Conclusions: Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The incidence of severe perioperative renal dysfunction in high-acuity patients has not been well-explored at the national level. The present study aimed to evaluate the trends in the incidence of perioperative acute kidney injury and renal replacement therapy as well as associated mortality among patients undergoing an emergency general surgery operation., Methods: This was a retrospective cohort study using the National Inpatient Sample to identify all adult patients (>18 y) without chronic kidney disease who underwent an emergency general surgery procedure from 2008 to 2016. The study cohort was stratified based on presence of acute kidney injury and need for renal replacement therapy postoperatively. A multivariable logistic regression model was developed to predict the odds of mortality and composite morbidity. Nonparametric trend analyses of acute kidney injury and renal replacement therapy incidence and associated mortality were performed., Results: Of an estimated 5,862,657 patients who underwent an emergency general surgery procedure during the study period, 7.4% patients developed an acute kidney injury and 0.48% patients required renal replacement therapy. Overall, the incidence of acute kidney injury (5.3%-19.4%) and renal replacement therapy (0.43%-0.93%) increased (P < .0001) over the study period. Even without need for renal replacement therapy, acute kidney injury was associated with greater odds of mortality and composite morbidity (adjusted odds ratio 5.2, 95% confidence interval [CI] 5.1-5.3) and mortality (adjusted odds ratio = 2.20, 95% CI 2.3-2.4), as well as greater costs of hospitalization and duration of stay., Conclusion: In this national study, we found that the incidence of acute kidney injury and renal replacement therapy after an emergency general surgery operation has increased. Both acute renal failure and hemodialysis were associated with much greater odds of morbidity and mortality. The apparent increase in the rate of acute kidney injury and renal replacement therapy warrant further investigation of mechanisms for monitoring and limiting the impact of organ malperfusion associated with emergency general surgery operations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: With increasing dissemination and improved survival after extracorporeal life support, also called extracorporeal membrane oxygenation, the decrease in readmissions after hospitalization involving extracorporeal life support is an emerging priority. The present study aimed to identify predictors of early readmission after extracorporeal life support at a national level., Methods: This was a retrospective cohort study using the Nationwide Readmissions Database. All patients ≥18 years who underwent extracorporeal life support from 2010 to 2015 were identified. Patients were stratified into the following categories of extracorporeal life support: postcardiotomy, primary cardiogenic shock, cardiopulmonary failure, respiratory failure, transplantation, and miscellaneous. The primary outcome of the study was the rate of 90-day rehospitalization after extracorporeal life support admission. A multivariable logistic regression model was developed to predict the odds of unplanned 90-day readmission. Kaplan-Meier analyses were also performed., Results: An estimated 18,748 patients received extracorporeal life support with overall mortality of 50.2%. Of the patients who survived hospitalization, 30.2% were discharged to a skilled nursing facility, and 21.1% were readmitted within 90 days after discharge. After adjusting for patient and hospital characteristics, cardiogenic shock was associated with the greatest odds of mortality (adjusted odds ratio 1.6; 95% confidence interval, 1.09-1.46; C-statistic, 0.64). The cohort with respiratory failure had decreased odds of readmission (adjusted odds ratio 0.76; 95% confidence interval, 0.58-0.99). Discharge to skilled nursing facility (adjusted odds ratio 1.64; 95% confidence interval, 1.36-1.97) was independently associated with readmission. Cardiac and respiratory-related readmissions comprised the majority of unplanned 90-day rehospitalizations., Conclusion: In this large analysis of readmissions after extracorporeal life support in adults, 21% of extracorporeal life support survivors were rehospitalized within 90 days of discharge. Disposition to a skilled nursing facility, but not advanced age nor female sex, was associated with readmission., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals., Methods: The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals., Results: Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals., Conclusion: Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although short-term outcomes of endovascular and open infrainguinal revascularization in patients with peripheral arterial disease have been previously reported, 30-day readmission and resource utilization after these procedures remain unknown., Methods: We used the 2010-2014 Nationwide Readmissions Database and the International Classification of Diseases, Ninth Edition, to identify patients with peripheral arterial disease undergoing either in-hospital endovascular or open infrainguinal revascularization., Results: Of an estimated 574,201 hospitalized patients treated for peripheral arterial disease, 308,056 and 266,145 underwent lower limb endovascular and open infrainguinal revascularization, respectively. Compared with patients who underwent open revascularization, endovascular patients were more commonly female (44.8% vs 36.7%, P < .001) and older (69.5 vs 67.2 years, P < .001). Moreover, they had higher rates of 30-day readmission (15.6% vs 13.5%, P < .001), in-hospital complications (22.3% vs 20.9%, P < .001), and in-hospital index mortality (2.1% vs 1.8%, P < .001). In contrast, risk-adjusted multivariable analysis found open revascularization to be independently associated with increased odds of 30-day readmission (odds ratio, 1.13; 95% confidence interval 1.10-1.16), index complications (odds ratio, 1.23; 95% confidence interval 1.20-1.27), and mortality (odds ratio, 1.26; 95% confidence interval 1.16-1.36) compared with those who underwent endovascular revascularization. Trend analysis revealed an overall decrease in the utilization of both endovascular and open revascularization procedures in the inpatient setting., Conclusion: Despite lower rates of adverse events compared to endovascular, open infrainguinal revascularization is independently associated with increased risk of short-term readmission, complications, and mortality. These findings should be considered in the selection of appropriate surgical therapy for lower extremity arterial occlusive disease., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Malnutrition is a modifiable risk factor for poor outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study is to highlight risk factors for hypoalbuminemia and develop a predictive model that identifies patients at risk for this condition before THA or TKA. The study retrospectively reviewed the National Surgical Quality Improvement Program database to analyze preoperative independent risk factors for a diagnosis of hypoalbuminemia in adult patients who underwent THA or TKA. These factors were used to create a preoperative risk model to predict hypoalbuminemia. Individuals with three or more risk factors in the seven-point model are predicted to have hypoalbuminemia in 20.4% of THA or 10.5% of TKA cases. Accurate identification of hypoalbuminemic patients may allow preoperative nutrition interventions to improve postoperative outcomes. (Journal of Surgical Orthopaedic Advances 28(2):97-103, 2019).

Purpose: Total knee arthroplasty (TKA) is increasing in frequency and cost. Optimization of discharge location may reduce total expenditure while maximizing patient outcomes. Although preoperative illness rating systems-including the American Society for Anesthesiologists Physical Classification System (ASA), severity of illness scoring system (SOI), and Mallampati rating scale (MP)-are associated with patient morbidity and mortality, their predictive value for discharge location, length of stay (LOS), and total costs remains unclear., Materials and Methods: We conducted a retrospective analysis of 677 TKA patients (550 primary and 127 revision) treated at a single institution. The influence of ASA, SOI, and MP scores on discharge locations, LOS, and total costs was assessed using multivariable regression analyses., Results: None of the systems were significant predictors of discharge location following TKA. SOI scores of major or higher (β=2.08 days, p＜0.001) and minor (β=-0.25 days, p=0.009) significantly predicted LOS relative to moderate scores. Total costs were also significantly predicted by SOI scores of major or higher (β=$6,155, p=0.022) and minor (β=-$1,163, p=0.007)., Conclusions: SOI scores may be harnessed as a predictive tool for LOS and total costs following TKA, but other mechanisms are necessary to predict discharge location.

Salamanders, such as the Mexican axolotl, are some of the few vertebrates fortunate in their ability to regenerate diverse structures after injury. Unlike mammals they are able to regenerate a fully functional spinal cord after injury. However, the molecular circuitry required to initiate a pro-regenerative response after spinal cord injury is not well understood. To address this question we developed a spinal cord injury model in axolotls and used in vivo imaging of labeled ependymoglial cells to characterize the response of these cells to injury. Using in vivo imaging of ion sensitive dyes we identified that spinal cord injury induces a rapid and dynamic change in the resting membrane potential of ependymoglial cells. Prolonged depolarization of ependymoglial cells after injury inhibits ependymoglial cell proliferation and subsequent axon regeneration. Using transcriptional profiling we identified c-Fos as a key voltage sensitive early response gene that is expressed specifically in the ependymoglial cells after injury. This data establishes that dynamic changes in the membrane potential after injury are essential for regulating the specific spatiotemporal expression of c-Fos that is critical for promoting faithful spinal cord regeneration in axolotl., (Copyright © 2015 Elsevier Inc. All rights reserved.)