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Objectives: To depict the current state of global surgery opportunities in United States ACGME-approved Otolaryngology residency programs and compare the characteristics of programs with and without these opportunities., Methods: In this cross-sectional analysis, websites of ACGME-accredited Otolaryngology residency programs were analyzed for information on program size, rank, age, and geographic region as obtained through the Doximity platform in 2023. Additional parameters were obtained for programs listing global surgery opportunities such as funding, faculty oversight, location/region, focus, and relationship to the community served. Data were tabulated and analyzed in Microsoft Excel and Stata., Results: Of the 131 ACGME-accredited Otolaryngology residency programs, 26 (20%) of programs advertised a global surgery opportunity. Nine (35%) of these promoted funding, 15 (58%) offered a clinical focus, one (4%) offered a research focus, and 10 (38%) offered a combined approach. The Midwest region had the most programs with global surgery opportunities (n = 8, 31%). Less than half (42%) of programs had an established partnership with local partners within low and middle-income countries (LMICs). When comparing programs, the average Doximity rank, average program age, and average program size of programs that offered global surgery opportunities was significantly higher than those that did not (37.2 vs. 71.5, 54 vs. 41, 19.5 vs. 13.7; all p < 0.05)., Conclusions: Approximately one-fifth of Otolaryngology training programs have a global surgery opportunity. Programs that offer these opportunities had a higher Doximity ranking, older program age, and a larger trainee cohort. These results highlight potential areas for expanding global surgery opportunities in academic institutions., Level of Evidence: NA Laryngoscope, 134:4501-4505, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Gender disparities in surgical training and assessment are described in the general surgery literature. Assessment disparities have not been explored in vascular surgery. We sought to investigate gender disparities in operative assessment in a national cohort of vascular surgery integrated residents (VIRs) and fellows (VSFs)., Methods: Operative performance and autonomy ratings from the Society for Improving Medical Professional Learning (SIMPL) application database were collected for all vascular surgery participating institutions from 2018 to 2023. Logistic generalized linear mixed models were conducted to examine the association of faculty and trainee gender on faculty and self-assessment of autonomy and performance. Data were adjusted for post-graduate year and case complexity. Random effects were included to account for clustering effects due to participant, program, and procedure., Results: One hundred three trainees (n = 63 VIRs; n = 40 VSFs; 63.1% men) and 99 faculty (73.7% men) from 17 institutions (n = 12 VIR and n = 13 VSF programs) contributed 4951 total assessments (44.4% by faculty, 55.6% by trainees) across 235 unique procedures. Faculty and trainee gender were not associated with faculty ratings of performance (faculty gender: odds ratio [OR], 0.78; 95% confidence interval [CI], 0.27-2.29; trainee gender: OR, 1.80; 95% CI, 0.76-0.43) or autonomy (faculty gender: OR, 0.99; 95% CI, 0.41-2.39; trainee gender: OR, 1.23; 95% CI, 0.62-2.45) of trainees. All trainees self-assessed at lower performance and autonomy ratings as compared with faculty assessments. However, women trainees rated themselves significantly lower than men for both autonomy (OR, 0.57; 95% CI, 0.43-0.74) and performance (OR, 0.40; 95% CI, 0.30-0.54)., Conclusions: Although gender was not associated with differences in faculty assessment of performance or autonomy among vascular surgery trainees, women trainees perceive themselves as performing with lower competency and less autonomy than their male colleagues. These findings suggest utility for exploring gender differences in real-time feedback delivered to and received by trainees and targeted interventions to align trainee self-perception with actual operative performance and autonomy to optimize surgical skill acquisition., Competing Interests: Disclosures M.L.W. is a consultant for W. L Gore & Associates., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The National Institutes of Health (NIH) is an essential source of funding for vascular surgeons conducting research. NIH funding is frequently used to benchmark institutional and individual research productivity, help determine eligibility for academic promotion, and as a measure of scientific quality. We sought to appraise the current scope of NIH funding to vascular surgeons by appraising the characteristics of NIH-funded investigators and projects. In addition, we also sought to determine whether funded grants addressed recent Society for Vascular Surgery (SVS) research priorities., Methods: In April 2022, we queried the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database for active projects. We only included projects that had a vascular surgeon as a principal investigator. Grant characteristics were extracted from the NIH Research Portfolio Online Reporting Tools Expenditures and Results database. Principal investigator demographics and academic background information were identified by searching institution profiles., Results: There were 55 active NIH awards given to 41 vascular surgeons. Only 1% (41/4037) of all vascular surgeons in the United States receive NIH funding. Funded vascular surgeons are an average of 16.3 years out of training; 37% (n = 15) are women. The majority of awards (58%; n = 32) were R01 grants. Among the active NIH-funded projects, 75% (n = 41) are basic or translational research projects, and 25% (n = 14) are clinical or health services research projects. Abdominal aortic aneurysm and peripheral arterial disease are the most commonly funded disease areas and together accounted for 54% (n = 30) of projects. Three SVS research priorities are not addressed by any of the current NIH-funded projects., Conclusions: NIH funding of vascular surgeons is rare and predominantly consists of basic or translational science projects focused on abdominal aortic aneurysm and peripheral arterial disease research. Women are well-represented among funded vascular surgeons. Although the majority of SVS research priorities receive NIH funding, three SVS research priorities are yet to be addressed by NIH-funded projects. Future efforts should focus on increasing the number of vascular surgeons receiving NIH grants and ensuring all SVS research priorities receive NIH funding., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)

Objective: As medical education systems increasingly move toward competency-based training, it is important to understand the tools available to assess competency and how these tools are utilized. The Society for Improving Medical Professional Learning (SIMPL) offers a smart phone-based assessment system that supports workplace-based assessment of residents' and fellows' operative autonomy, performance, and case complexity. The purpose of this study was to characterize implementation of the SIMPL app within vascular surgery integrated residency (0+5) and fellowship (5+2) training programs., Methods: SIMPL operative ratings recorded between 2018 and 2022 were collected from all participating vascular surgery training institutions (n = 9 institutions with 5+2 and 0+5 programs; n = 4 institutions with 5+2 program only). The characteristics of programs, trainees, faculty, and SIMPL operative assessments were evaluated using descriptive statistics., Results: Operative assessments were completed for 2457 cases by 85 attendings and 86 trainees, totaling 4615 unique operative assessment ratings. Attendings included dictated feedback in 52% of assessments. Senior-level residents received more assessments than junior-level residents (postgraduate year [PGY]1-3, n = 439; PGY4-5, n = 551). Performance ratings demonstrated increases from junior to senior trainees for both resident and fellow cohorts with "performance-ready" or "exceptional performance" ratings increasing by nearly two-fold for PGY1 to PGY5 residents (28.1% vs 40.6%), and from first- to second-year fellows (PGY6, 46.7%; PGY7, 60.3%). Similar gains in autonomy were demonstrated as trainees progressed through training. Senior residents were more frequently granted autonomy with "supervision only" than junior residents (PGY1, 8.7%; PGY5, 21.6%). "Supervision only" autonomy ratings were granted to 21.8% of graduating fellows. Assessment data included a greater proportion of complex cases for senior compared with junior fellows (PGY6, 20.9% vs PGY7, 26.5%). Program Directors felt that faculty and trainee buy-in were the main barriers to implementation of the SIMPL assessment app., Conclusions: This is the first description of the SIMPL app as an operative assessment tool within vascular surgery that has been successfully implemented in both residency and fellowship programs. The assessment data demonstrates expected progressive gains in trainees' autonomy and performance, as well as increasing case complexity, across PGY years. Given the selection of SIMPL as the assessment platform for required American Board of Surgery and Vascular Surgery Board Entrustable Professional Activities assessments, understanding facilitators and barriers to implementation of workplace-based assessments using this app is imperative, particularly as we move toward competency-based medical education., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Keratinocyte carcinomas are the most common cancers in the US. However, keratinocyte carcinomas are not included in US national cancer registries, and information on the anatomic locations of keratinocyte carcinomas is lacking., Objective: To investigate the anatomic location of keratinocyte carcinomas in the US using a large claims data set., Design, Setting, and Participants: We performed a cohort study using a deidentified, random sample of 4 999 999 fee-for-service Medicare beneficiaries aged 65 years or older (2009-2018)., Main Outcomes and Measures: Proportion of procedurally treated keratinocyte carcinomas at each anatomic location, identified by linking diagnosis and treatment codes., Results: A total of 2 415 514 keratinocyte carcinomas were identified in 792 393 beneficiaries. The mean (SD) age was 76.6 (8.1) years, 410 364 (51.8%) were women, and 96.7% were White. Of the 2 415 514 keratinocyte carcinomas, 796 542 could be subtyped into basal cell carcinoma (33.0%), 927 984 into squamous cell carcinoma (38.4%), and 690 988 (28.6%) could not be subtyped. The most common location of squamous cell carcinomas was the head and/or neck (44.3%) followed by upper limbs (26.7%). The most common location of basal cell carcinomas was head and/or neck (63.8%), followed by trunk (14.9%). In women, keratinocyte carcinomas were most common on the head and/or neck (47.3%) followed by upper and lower limb (18.5% and 16.6%, respectively). In men, keratinocyte carcinomas were most common on the head and/or neck (58.7%) followed by upper limb and trunk (17.3% and 11.4%, respectively)., Conclusions and Relevance: The results of this large Medicare cohort study highlight the anatomic locations of keratinocyte carcinomas over recent years and show the predominance of lesions occurring at head and/or neck anatomic location. This foundational information on keratinocyte carcinoma anatomic locations in the US is valuable for improved keratinocyte risk factor differentiation and skin cancer surveillance.

Objective: Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content., Methods: The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ 2 tests., Results: During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001)., Conclusions: The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Early in 2021, many people began sharing that they experienced unexpected menstrual bleeding after SARS-CoV-2 inoculation. We investigated this emerging phenomenon of changed menstrual bleeding patterns among a convenience sample of currently and formerly menstruating people using a web-based survey. In this sample, 42% of people with regular menstrual cycles bled more heavily than usual, while 44% reported no change after being vaccinated. Among respondents who typically do not menstruate, 71% of people on long-acting reversible contraceptives, 39% of people on gender-affirming hormones, and 66% of postmenopausal people reported breakthrough bleeding. We found that increased/breakthrough bleeding was significantly associated with age, systemic vaccine side effects (fever and/or fatigue), history of pregnancy or birth, and ethnicity. Generally, changes to menstrual bleeding are not uncommon or dangerous, yet attention to these experiences is necessary to build trust in medicine.

In breast cancer, genetic heterogeneity, the lack of actionable targets and immune evasion all contribute to the limited clinical response rates to immune checkpoint blockade therapy. Here, we report a high-throughput screen based on the functional interaction of mouse- or patient-derived breast tumour organoids and tumour-specific cytotoxic T cells for the identification of epigenetic inhibitors that promote antigen presentation and potentiate T-cell-mediated cytotoxicity. We show that the epigenetic inhibitors GSK-LSD1, CUDC-101 and BML-210, identified by the screen, display antitumour activities in orthotopic mammary tumours in mice, that they upregulate antigen presentation mediated by the major histocompatibility complex class I on breast tumour cells and that treatment with BML-210 substantially sensitized breast tumours to the inhibitor of the checkpoint programmed death-1. Standardized measurements of tumour-cell killing activity facilitated by tumour-organoid-T-cell screens may help with the identification of candidate immunotherapeutics for a range of cancers., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Increased risk donors in paediatric heart transplantation have characteristics that may increase the risk of infectious disease transmission despite negative serologic testing. However, the risk of disease transmission is low, and refusing an IRD offer may increase waitlist mortality. We sought to determine the risks of declining an initial IRD organ offer., Methods and Results: We performed a retrospective analysis of candidates waitlisted for isolated PHT using 20072017 United Network of Organ Sharing datasets. Match runs identified candidates receiving IRD offers. Competing risks analysis was used to determine mortality risk for those that declined an initial IRD offer with stratified Cox regression to estimate the survival benefit associated with accepting initial IRD offers. Overall, 238/1067 (22.3%) initial IRD offers were accepted. Candidates accepting an IRD offer were younger (7.2 versus 9.8 years, p < 0.001), more often female (50 versus 41%, p = 0.021), more often listed status 1A (75.6 versus 61.9%, p < 0.001), and less likely to require mechanical bridge to PHT (16% versus 23%, p = 0.036). At 1- and 5-year follow-up, cumulative mortality was significantly lower for candidates who accepted compared to those that declined (6% versus 13% 1-year mortality and 15% versus 25% 5-year mortality, p = 0.0033). Decline of an IRD offer was associated with an adjusted hazard ratio for mortality of 1.87 (95% CI 1.24, 2.81, p < 0.003)., Conclusions: IRD organ acceptance is associated with a substantial survival benefit. Increasing acceptance of IRD organs may provide a targetable opportunity to decrease waitlist mortality in PHT.

Background: The electronic health record has improved medical billing, research, and sharing of patient data, but its clinical use by physicians has been linked to rising physician burnout leading to numerous subjective editorials about the electronic health record inefficiencies and detriment to frontline caregivers. This study aimed to quantify electronic health record use by surgeons., Methods: The study is a retrospective review and descriptive analysis of deidentified electronic health record data from September 2016 to June 2017. A binary time series was created for each attending to calculate electronic health record system login times. The primary outcome was the total amount of time a surgeon logged into the electronic health record system during the study period., Results: Fifty-one general surgery attendings (31 males, 20 females), spanning 9 specialties spent a mean of 2.0 hours per day and 13.8 hours per week logged into the electronic health record. The top 15% of users were logged in for an average of 4.6 hours per weekday. Sixty-five percent of overall electronic health record use occurred on-site, and 35% was remote. A greater proportion of remote use occurred during nighttime hours and Sundays. Clinic days required the largest amount of electronic health record use time compared with operating room and administrative days., Conclusion: General surgery attendings spend a considerable amount of time using the electronic health record. Ultimately, the goal of these quantitative electronic health record results is to correlate with burnout and job satisfaction data to facilitate the implementation of programs to improve efficiency and decrease the burden of charting. Further investigation needs to focus on subgroups who are high electronic health record users to better identify the barriers to efficient electronic health record use., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Expertise in laparoscopic surgery is realized through both manual dexterity and efficient eye movement patterns, creating opportunities to use gaze information in the educational process. To better understand how expert gaze behaviors are acquired through deliberate practice of technical skills, three surgeons were assessed and five novices were trained and assessed in a 5-visit protocol on the Fundamentals of Laparoscopic Surgery peg transfer task. The task was adjusted to have a fixed action sequence to allow recordings of dwell durations based on pre-defined areas of interest (AOIs). Trained novices were shown to reach more than 98% (M = 98.62%, SD = 1.06%) of their behavioral learning plateaus, leading to equivalent behavioral performance to that of surgeons. Despite this equivalence in behavioral performance, surgeons continued to show significantly shorter dwell durations at visual targets of current actions and longer dwell durations at future steps in the action sequence than trained novices (ps ≤ .03, Cohen's ds > 2). This study demonstrates that, while novices can train to match surgeons on behavioral performance, their gaze pattern is still less efficient than that of surgeons, motivating surgical training programs to involve eye tracking technology in their design and evaluation., Competing Interests: The author(s) declare(s) that the contents of the article are in agreement with the ethics described in http://biblio.unibe.ch/portale/elibrary/BOP/jemr/ethics.html and that there is no conflict of interest regarding the publication of this paper.

Radiologic techniques remain the main method for early detection for breast cancer and are critical to achieve a favorable outcome from cancer. However, more sensitive detection methods to complement radiologic techniques are needed to enhance early detection and treatment strategies. Using our recently established culturing method that allows propagation of normal and cancerous breast epithelial cells of luminal origin, flow cytometry characterization, and genomic sequencing, we show that cancer cells can be detected in breast milk. Cells derived from milk from the breast with cancer were enriched for CD49f + /EpCAM - , CD44 + /CD24 - , and CD271 + cancer stem-like cells (CSC). These CSCs carried mutations within the cytoplasmic retention domain of HDAC6, stop/gain insertion in MORF4L1, and deletion mutations within SWI/SNF complex component SMARCC2. CSCs were sensitive to HDAC6 inhibitors, BET bromodomain inhibitors, and EZH2 inhibitors, as mutations in SWI/SNF complex components are known to increase sensitivity to these drugs. Among cells derived from breast milk of additional ten women not known to have breast cancer, two of them contained cells that were enriched for the CSC phenotype and carried mutations in NF1 or KMT2D, which are frequently mutated in breast cancer. Breast milk-derived cells with NF1 mutations also carried copy-number variations in CDKN2C, PTEN, and REL genes. The approach described here may enable rapid cancer cell characterization including driver mutation detection and therapeutic screening for pregnancy/postpartum breast cancers. Furthermore, this method can be developed as a surveillance or early detection tool for women at high risk for developing breast cancer. SIGNIFICANCE: These findings describe how a simple method for characterization of cancer cells in pregnancy and postpartum breast cancer can be exploited as a surveillance tool for women at risk of developing breast cancer., (©2020 American Association for Cancer Research.)

There is debate surrounding the appropriate threshold for lymph node harvest during esophagectomy in patients with esophageal cancer, specifically for those receiving preoperative radiation. The purpose of this study was to determine the impact of lymph node yield on survival in patients receiving preoperative chemoradiation for esophageal cancer. The National Cancer Database (NCDB) was utilized to identify patients with esophageal cancer that received preoperative radiation. The cohort was divided into patients undergoing minimal (<9) or extensive (≥9) lymph node yield. Demographic, operative, and postoperative outcomes were compared between the groups. Kaplan-Meier analysis with the log rank test was used to compare survival between the yield groups. Cox proportional hazards model was used to determine the association between lymph node yield and survival. In total, 886 cases were included: 349 (39%) belonging to the minimal node group and 537 (61%) to the extensive group. Unadjusted 5-year survival was similar between the minimal and extensive groups, respectively (37.3% vs. 38.8%; P > 0.05). After adjustment using Cox regression, extensive lymph node yield was associated with survival (hazard ratio 0.80, confidence interval 0.66-0.98, P = 0.03). This study suggests that extensive lymph node yield is advantageous for patients with esophageal cancer undergoing esophagectomy following induction therapy. This most likely reflects improved diagnosis and staging with extensive yield., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The optimal role of radial artery grafts in coronary artery bypass grafting (CABG) remains uncertain. The purpose of this study was to examine angiographic and clinical outcomes following CABG among patients who received a radial artery graft., Methods: Patients in the angiographic cohort of the PREVENT-IV trial were stratified based upon having received a radial artery graft or not during CABG. Baseline characteristics and 1-year angiographic and 5-year clinical outcomes were compared between patients., Results: Of 1,923 patients in the angiographic cohort of PREVENT-IV, 117 received a radial artery graft. These patients had longer surgical procedures (median 253 vs 228 minutes, P < .001) and had a greater number of grafts placed (P < .0001). Radial artery grafts had a graft-level failure rate of 23.0%, which was similar to vein grafts (25.2%) and higher than left internal mammary artery grafts (8.3%). The hazard of the composite clinical outcome of death, myocardial infarction, or repeat revascularization was similar for both cohorts (adjusted hazard ratio 0.896, 95% CI 0.609-1.319, P = .58). Radial graft failure rates were higher when used to bypass moderately stenotic lesions (<75% stenosis, 37% failure) compared with severely stenotic lesions (≥75% stenosis, 15% failure)., Conclusions: Radial artery grafts had early failure rates comparable to saphenous vein and higher than left internal mammary artery grafts. Use of a radial graft was not associated with a different rate of death, myocardial infarction, or postoperative revascularization. Despite the significant potential for residual confounding associated with post hoc observational analyses of clinical trial data, these findings suggest that when clinical circumstances permit, the radial artery is an acceptable alternative to saphenous vein and should be used to bypass severely stenotic target vessels., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Geographic access to transcatheter aortic replacement (TAVR) centers varies in the United States as a result of controlled expansion through minimum volume requirements., Objective: To describe the current geographic access to TAVR centers in the United States., Design, Setting, and Participants: Observational study from June 1, 2015, to June 30, 2017. United States census data were used to describe access to TAVR center. Google Maps and the Society of Thoracic Surgeons American College of Cardiology Transcatheter Valve Therapy Registry were used to describe characteristics of patients undergoing successful TAVR according to proximity to implanting center. The study analyzed 47 527 537 individuals 65 years and older in the United States and 31 098 patients who underwent successful transfemoral TAVR, were linked to fee-for-service Medicare, and had a measurable driving time., Main Outcomes and Measures: Median driving distance to a TAVR center., Results: Among 40 537 zip codes in the United States, 490 (1.2%) contained a TAVR center, and among 305 hospital referral regions (HRR), 234 (76.7%) contained a TAVR center. Of the 31 749 patients who underwent successful transfemoral TAVR and were linked to fee-for-service Medicare, 31 098 had a measurable driving time. Mean (SD) age was 82.4 (6.9) years, 14 697 patients (47.3%) were women, and 7422 (23.87%) lived in a rural area. This translated to 1 232 568 of 47 527 537 individuals (2.6%) 65 years and older living in a zip code with a TAVR center and 43 789 169 (92.1%) living in an HRR with a TAVR center. Among 31 749 patients who underwent successful transfemoral TAVR and were linked to fee-for-service Medicare, 31 098 had a measurable driving time. All of these patients (100.0%) underwent their procedure in a TAVR center within their HRR, with 1350 (4.3%) undergoing TAVR in a center within their home zip code. Median driving time to implanting TAVR center was 35.0 minutes (IQR, 20.0-70.0 minutes), ranging from 2.0 minutes to 18 hours and 48 minutes., Conclusions and Relevance: Most US individuals 65 years and older live in an HRR with a TAVR center. Among patients undergoing successful transfemoral TAVR, median driving time to implanting center was 35.0 minutes. Within the context of the US health care system, where certain advanced procedures and specialized care are centralized, TAVR services have significant penetration. More studies are required to evaluate the effect of geographic location of TAVR sites on access to TAVR procedures among individuals with an indication for a TAVR within the US population.

Background: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that delivers constant, low electrical current resulting in changes to cortical excitability. Prior work suggests it may enhance motor learning giving it the potential to augment surgical technical skill acquisition., Objectives: The aim of this study was to test the efficacy of tDCS, coupled with motor skill training, to accelerate laparoscopic skill acquisition in a pre-registered (NCT03083483), double-blind and placebo-controlled study. We hypothesized that relative to sham tDCS, active tDCS would accelerate the development of laparoscopic technical skills, as measured by the Fundamentals of Laparoscopic Surgery (FLS) Peg Transfer task quantitative metrics., Methods: In this study, sixty subjects (mean age 22.7 years with 42 females) were randomized into sham or active tDCS in either bilateral primary motor cortex (bM1) or supplementary motor area (SMA) electrode configurations. All subjects practiced the FLS Peg Transfer Task during six 20-min training blocks, which were preceded and followed by a single trial pre-test and post-test. The primary outcome was changes in laparoscopic skill performance over time, quantified by group differences in completion time from pre-test to post-test and learning curves developed from a calculated score accounting for errors., Results: Learning curves calculated over the six 20-min training blocks showed significantly greater improvement in performance for the bM1 group than the sham group (t = 2.07, p = 0.039), with the bM1 group achieving approximately the same amount of improvement in 4 blocks compared to the 6 blocks required of the sham group. The SMA group also showed greater mean improvement than sham, but exhibited more variable learning performance and differences relative to sham were not significant (t = 0.85, p = 0.400). A significant main effect was present for pre-test versus post-test times (F = 133.2, p < 0.001), with lower completion times at post-test, however these did not significantly differ for the training groups., Conclusion: Laparoscopic skill training with active bilateral tDCS exhibited significantly greater learning relative to sham. The potential for tDCS to enhance the training of surgical skills, therefore, merits further investigation to determine if these preliminary results may be replicated and extended., Competing Interests: Declaration of competing interest None., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Lung transplantation offers a survival benefit for patients with end-stage lung disease. When suitable donors are identified, centers must accept or decline the offer for a matched candidate on their waitlist. The degree to which variability in per-center offer acceptance practices impacts candidate survival is not established. The purpose of this study was to determine the degree of variability in per-center rates of lung transplantation offer acceptance and to ascertain the associated contribution to observed differences in per-center waitlist mortality., Methods: We performed a retrospective cohort study of candidates waitlisted for lung transplantation in the US using registry data. Logistic regression was fit to assess the relationship of offer acceptance with donor, candidate, and geographic factors. Listing center was evaluated as a fixed effect to determine the adjusted per-center acceptance rate. Competing risks analysis employing the Fine-Gray model was undertaken to establish the relationship between adjusted per-center acceptance and waitlist mortality., Results: Of 15,847 unique organ offers, 4,735 (29.9%) were accepted for first-ranked candidates. After adjustment for important covariates, transplant centers varied markedly in acceptance rate (9%-67%). Higher cumulative incidence of 1-year waitlist mortality was associated with lower acceptance rate. For every 10% increase in adjusted center acceptance rate, the risk of waitlist mortality decreased by 36.3% (sub-distribution hazard ratio 0.637; 95% confidence interval 0.592-0.685)., Conclusions: Variability in center-level behavior represents a modifiable risk factor for waitlist mortality in lung transplantation. Further intervention is needed to standardize center-level offer acceptance practices and minimize waitlist mortality., (Copyright © 2020 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

We suggested previously that hippocampal slices were protected from hypoxic depolarization and swelling by preincubating them at room temperature (Kreisman et al., 2000). We postulated that hypothermic preconditioning induced tolerance in our slices, which protected against hypoxic depolarization and swelling. Control hippocampal slices were incubated at 34-35 °C for two hours and the response to 10 min of severe hypoxia was compared to slices which were preconditioned for two hours at room temperature (22-23 °C) prior to warming to 34-35 °C. Recordings of the extracellular DC potential provided an index of tissue depolarization and changes in tissue light transmittance provided an index of swelling. Hypothermic preconditioning significantly reduced hypoxia-induced swelling, particularly in CA3 and the dentate inner blade. Since erythropoietin (EPO) had been shown to mediate hypoxic preconditioning, we tested whether EPO also mediated hypothermic preconditioning in our slices. Recombinant rat EPO (1-10 micromolar) mitigated hypoxia-induced swelling and depolarization in dentate inner blade of unconditioned slices in a dose-dependent manner. We also blocked the protective effects of hypothermic preconditioning on hypoxic depolarization and swelling in the inner blade of the dentate gyrus by administering soluble EPO receptor in the bath and treating slices with wortmannin to block phosphorylation of PI3 kinase, a critical step in the activation of the downstream neuroprotectant, Akt. These results suggest that EPO mediates tolerance to hypoxic depolarization and swelling induced by hypothermic preconditioning. They also emphasize that various preincubation protocols used in experiments with hippocampal slices may differentially affect basal electrophysiological and metabolic properties of those slices., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Despite implementation of Morbidity and Mortality (M&M) Conference across surgical graduate medical education, sparse literature exists regarding the attendance and involvement of medical students. We sought to examine student involvement and learning objectives for M&M on a national level., Methods: A survey was distributed through the Association for Surgical Education Committee of Clerkship Directors. Questions examined demographics, teaching practices regarding M&M, and student learning objectives., Results: Forty-eight responses were collected reflecting practices of weekly M&M (96%) and required student attendance (93%). Students are observers in 61% of M&Ms, observer with questions in 37%, and presenter at 2%. Learning objectives for M&M highlighted exposing students to conference style (76%), reflective learning (63%), and highlighting medical error (78%)., Conclusions: It is the national standard for medical students to attend weekly M&M. Student learning objectives reflect desires to improve exposure to this style of teaching conference and understanding the gravity of medical error., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: The aim of this study was to assess the real-world impact of transcatheter mitral valve repair (TMVR) on hospitalizations and Medicare costs pre- versus post-TMVR., Background: TMVR is effective in degenerative mitral regurgitation (MR) and appropriately selected patients with functional MR with high surgical risk., Methods: Patients undergoing TMVR in the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry from 2013 to 2018 were linked to Medicare claims data. Rates of hospitalizations, hospitalized days, and Medicare costs were compared 1-year pre-TMVR to 1-year post-TMVR., Results: Across 246 sites, 4,970 patients with a median age of 83 years (interquartile range: 77 to 87 years) were analyzed. The TMVR indication was degenerative MR in 77.5% and functional MR in 16.7%. From pre- to post-TMVR, heart failure (HF) hospitalization rates (479 vs. 370 hospitalizations/1,000 person-years; rate ratio [RR]: 0.77) and cardiovascular hospitalizations (838 vs. 632; RR: 0.75) decreased significantly (p < 0.001 for all). Similarly, the rates of hospitalized days decreased for HF and cardiovascular causes (p < 0.05 for all). Following TMVR, the odds of having no Medicare costs for HF hospitalizations increased (69% vs. 79%; odds ratio: 1.67; p < 0.001). However, the average total Medicare costs per day alive among patients with any HF hospitalizations after TMVR increased significantly (p < 0.001). The HF hospitalization rates decreased for patients with functional MR (683 vs. 502; RR: 0.74) and those with degenerative MR (431 vs. 337; RR: 0.78) (p < 0.001)., Conclusions: TMVR is associated with a decrease in cardiovascular and HF hospitalizations and a greater likelihood of having no HF Medicare costs in the year after TMVR, regardless of MR etiology. Further work is necessary to elucidate the reasons for increased costs among patients with HF hospitalizations post-TMVR., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Fragmented care following elective surgery has been associated with poor outcomes. The association between fragmented care and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. We examined patients who underwent TAVI from 2011 to 2015 at 374 sites in the STS/ACC TVT Registry, linked to Center for Medicare and Medicaid Services claims data. Fragmented care was defined as at least one readmission to a site other than the implanting TAVI center within 90 days after discharge, whereas continuous care was defined as readmission to the same implanting center. We compared adjusted 1-year outcomes, including stroke, bleeding, heart failure, mortality, and all-cause readmission in patients who received fragmented versus continuous care. Among 8,927 patients who received a TAVI between 2011 and 2015, 27.4% were readmitted within 90 days of discharge. Most patients received fragmented care (57.0%). Compared with the continuous care group, the fragmented care group was more likely to have severe chronic lung disease, cerebrovascular disease, and heart failure. States that had lower TAVI volume per Center for Medicare and Medicaid Services population had greater fragmentation. Patients living > 30 minutes from their TAVI center had an increased risk of fragmented care 1.07 (confidence interval [CI] 1.06 to 1.09, p < 0.001). After adjustment for comorbidities and procedural complications, fragmented care was associated with increased 1-year mortality (hazards ratio 1.18, CI 1.04 to 1.35, p = 0.010) and all-cause readmission (hazards ratio 1.08, CI 1.00 to 1.16, p = 0.051. In conclusion, fragmented readmission following TAVI is common, and is associated with increased 1-year mortality and readmission. Efforts to improve coordination of care may improve these outcomes and optimize long-term benefits yielded from TAVI., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The optimal transplant strategy for patients with end-stage lung disease complicated by secondary pulmonary hypertension (PH) is controversial. The aim of this study is to define the role of single lung transplantation in this population., Methods: We performed a retrospective study of lung transplant recipients using the Organ Procurement and Transplantation Network/United Network for Organ Sharing Standard Transplant Analysis and Research registry. Adult recipients that underwent isolated lung transplantation between May 2005 and June 2015 for end-stage lung disease because of obstructive or restrictive etiologies were identified. Patients were stratified by mean pulmonary artery pressure ([mPAP] ≥ or < 40 mm Hg) and by treatment-single (SOLT) or bilateral (BOLT) orthotopic lung transplantation. The primary outcome measure was overall survival (OS), which was estimated using the Kaplan-Meier method and compared by the log-rank test. To adjust for donor and recipient confounders, Cox proportional hazards models were developed to estimate the adjusted hazard ratio of mortality associated with elevated mPAP in SOLT and BOLT recipients., Results: A total of 12,392 recipients met inclusion criteria. Of recipients undergoing SOLT, those with mPAP ≥40 were shown to have lower survival, with 5-year OS of 43.9% (95% confidence interval 36.6-52.7; p = 0.007). Of recipients undergoing BOLT, OS was superior to SOLT, and no difference in 5-year OS between mPAP ≥ and <40 was observed (p = 0.15). In the adjusted analysis, mPAP ≥40 mm Hg was found to be an independent predictor for mortality in SOLT, but not BOLT recipients. This finding remained true on multivariable analysis. In patients undergoing SOLT, mPAP ≥40 was associated with an adjusted hazard ratio for mortality of 1.31 (1.08-1.59, p = 0.07). In BOLT, mPAP was not associated with increased hazard (adjusted hazard ratio 1.04, p = 0.48)., Conclusions: There is a reduced survival when a patient with severe secondary PH undergoes SOLT. This increased mortality hazard is not seen in BOLT. It appears that a BOLT may negate the adverse effect that severe PH has on OS, and may be superior to SOLT in patients with mPAP over 40 mm Hg., (Copyright © 2019 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this project was to assess the best measure for postoperative outcomes by comparing 30-day and 90-day mortality rates after surgery for non-small cell lung cancer using the National Cancer Database. Secondarily, hospital performance was examined at multiple postoperative intervals to assess changes in ranking based on mortality up to 1 year after surgery., Methods: Patients who had undergone surgery for non-small cell lung cancer between 2004 and 2013 were identified in the National Cancer Database. Mortality rates at 30 days and 90 days were compared after adjusting for several patient characteristics, tumor variables, and hospital procedural volume using generalized logistic mixed models. Subsequently, mixed model logistic regression models were employed to evaluate hospital performance based on calculated mortality at prespecified time points., Results: A total of 303,579 patients with non-small cell lung cancer were included for analysis. The 90-day mortality was almost double the 30-day mortality (3.0% vs 5.7%). Several patient characteristics, tumor features, and hospital volume were significantly associated with mortality at both 30 days and 90 days. Hospital rankings fluctuate appreciably between early mortality time points, which is additional evidence that quality metrics need to be based on later mortality time points., Conclusions: Thirty-day mortality is the commonly accepted quality measure for thoracic surgeons; however, hospital rankings may be inaccurate if based on this variable alone. Mortality after 90 days appears to be a threshold after which there is less variability in hospital ranking and should be considered as an alternative quality metric in lung cancer surgery., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There is debate whether simultaneous lung-liver transplant (LLT) long-term outcomes warrant allocation of 2 organs to a single recipient. We hypothesized that LLT recipients would have improved posttransplant survival compared with matched single-organ lung recipients with an equivalent degree of liver dysfunction., Methods: The Organ Procurement and Transplant Network/United Network for Organ Sharing STAR file was queried for adult candidates for LLT and isolated lung transplantation from 2006 to 2016. Waitlist mortality and transplant odds were calculated for all candidates. Donor and recipient demographic characteristics were compiled and compared. The LLT recipients were matched 1:2 with a nearest neighbor method to single-organ lung recipients. Kaplan-Meier methods with log-rank test compared long-term survival between groups. Univariate regression was used to calculate the association of LLT and mortality within 6 months of transplant. A proportional hazards model was used to calculate risk-adjusted mortality after 6 months posttransplantation., Results: Thirty-eight LLT patients were matched to 75 single-organ lung recipients. After matching, no differences in baseline demographics or liver function were observed between cohorts. Length of stay was significantly longer in LLT recipients compared to isolated lung recipients (45.89 days vs 22.44 days, P < 0.001). There was no significant difference in survival probability between LLT and isolated lung transplant (1 y, 89.5% vs 86.7%; 5 y, 67.0% vs 64.6%; P = 0.20)., Conclusions: After matching for patient characteristics and level of liver dysfunction, survival in simultaneous LLT was comparable to isolated lung transplantation. Although this population is unique, the clinical picture prompting liver transplant is not clear. National guidelines to better elucidate patient selection are needed.

Background: Hospital readmission after pediatric cardiac surgery is incompletely understood. This study analyzed data from The Society of Thoracic Surgeons Congenital Heart Surgery Database to determine prevalence, to describe patient characteristics, and to evaluate risk factors for readmission., Methods: Readmission was defined by the "readmission within 30 days after discharge" field. Routine variables were summarized. Regression analysis was used to identify factors associated with readmission., Results: The study cohort included 56,429 patient records from 100 centers. Overall, 6,208 (11%) patients were readmitted. The most common reasons for readmission were respiratory or airway complications (14.2%), septic or infectious complications (11.4%), and reasons not related to the preceding surgical procedure (20.2%). Primary reason for readmission varied across benchmark operation groups. In multivariable analysis, factors associated with increased odds of readmission included the presence of noncardiac abnormalities (odds ratio [OR], 1.24), chromosomal abnormalities or genetic syndromes (OR, 1.24), preoperative mechanical circulatory support (OR, 1.36), other preoperative factors (OR, 1.21), prior cardiac surgery (OR, 1.31), Hispanic ethnicity (OR, 1.13), higher STAT procedural complexity (Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery) (STAT level 3 vs 1, OR, 1.22; STAT 4 vs 1, OR, 1.48; STAT 5 vs 1, OR, 2.62), prolonged postoperative length of stay (OR, 1.07 per day from 0 to 14 days; OR, 1.01 per week >14 days), any major complication (OR, 1.27), any other postoperative complications (OR, 2.00), and discharge on a weekday (OR, 1.07)., Conclusions: Readmission is common after congenital heart surgery, mostly for noncardiovascular reasons. Process improvement initiatives targeted at high-risk patients could minimize its impact., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hartmann's procedure for diverticulitis is a common procedure, with highly variable rates and timing of colostomy reversal. The aim of this study was to evaluate the impact of race and insurance coverage on reversal within 2 years of Hartmann's procedure for diverticulitis., Methods: The Healthcare Cost and Utilization Project (HCUP) State Inpatient Database of five states (2007-2010) was queried for patients who had Hartmann's procedure in the setting of diverticulitis. Patients were grouped by race and insurance status, and multivariable adjustment was performed to evaluate rate and timing of colostomy takedown at 2 years., Results: Among 11,019 patients who had Hartmann's procedure for diverticulitis, 6900 (69%) patients had colostomy reversal by 2 years, with a median time to reversal of 19 weeks. Compared to white patients with private insurance, combinations of black race and non-private insurance significantly reduced likelihood of colostomy reversal at 2 years across all combinations. Black patients without insurance had the lowest likelihood of reversal at 2 years (OR 0.27, 95% CI 0.14-0.51, p < 0.001). For patients who had colostomy reversal within 2 years, black patients without insurance had a significant delay in time to reversal (11 weeks, 95% CI 6-16, p < 0.001) compared to white patients with private insurance, and delays persisted across all other groups., Conclusions: Black patients and those without private insurance experienced significantly lower rates of, and delayed time to, colostomy reversal compared to white patients with private insurance. These disparities must be considered for allocation of resources in marginalized communities.

Purpose: Genetic ancestry influences evolutionary pathways of cancers. However, whether ancestry influences cancer-induced field defects is unknown. The goal of this study was to utilize ancestry-mapped true normal breast tissues as controls to identify cancer-induced field defects in normal tissue adjacent to breast tumors (NATs) in women of African American (AA) and European (EA) ancestry., Experimental Design: A tissue microarray comprising breast tissues of ancestry-mapped 100 age-matched healthy women from the Komen Tissue Bank (KTB) at Indiana University (Indianapolis, IN) and tumor-NAT pairs from 100 women (300 samples total) was analyzed for the levels of ZEB1, an oncogenic transcription factor that is central to cell fate, mature luminal cell-enriched estrogen receptor alpha (ERα), GATA3, FOXA1, and for immune cell composition., Results: ZEB1 + cells, which were localized surrounding the ductal structures of the normal breast, were enriched in the KTB-normal of AA compared with KTB-normal of EA women. In contrast, in EA women, both NATs and tumors compared with KTB-normal contained higher levels of ZEB1 + cells. FOXA1 levels were lower in NATs compared with KTB-normal in AA but not in EA women. We also noted variations in the levels of GATA3, CD8 + T cells, PD1 + immune cells, and PDL1 + cell but not CD68 + macrophages in NATs of AA and EA women. ERα levels did not change in any of our analyses, pointing to the specificity of ancestry-dependent variations., Conclusions: Genetic ancestry-mapped tissues from healthy individuals are required for proper assessment and development of cancer-induced field defects as early cancer detection markers. This finding is significant in light of recent discoveries of influence of genetic ancestry on both normal biology and tumor evolution., (©2019 American Association for Cancer Research.)

Background: A right-sided pneumonectomy after induction therapy for non-small cell lung cancer (NSCLC) has been shown to be associated with significant perioperative risk. We examined the effect of laterality on long-term survival after induction therapy and pneumonectomy using the National Cancer Data Base., Methods: Perioperative and long-term outcomes of patients who underwent pneumonectomy after induction chemotherapy, with or without radiotherapy, from 2004 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis., Results: During the study period, 1,465 patients (right, 693 [47.3%]; left, 772 [52.7%]) met inclusion criteria. Right-sided pneumonectomy was associated with significantly higher 30-day (8.2% [57 of 693] vs 4.2% [32 of 772], p < 0.01) and 90-day mortality (13.6% [94 of 693] vs 7.9% [61 of 772], p < 0.01), and right-sided pneumonectomy was a predictor of higher 90-day mortality (odds ratio, 2.23; p < 0.01). However, overall 5-year survival between right and left pneumonectomy was not significantly different in unadjusted (37.6% [95% confidence interval {CI}, 0.34 to 0.42] vs 35% [95% CI, 0.32 to 0.39], log-rank p = 0.94) or multivariable analysis (hazard ratio, 1.07; 95% CI, 0.92 to 1.25; p = 0.40). A propensity score-matched analysis of 810 patients found no significant differences in 5-year survival between the right-sided versus left-sided groups (34.7% [95% CI, 0.30 to 0.40] vs 34.1%, [95% CI, 0.29 to 0.39], log-rank p = 0.86)., Conclusions: In this national analysis, right-sided pneumonectomy after induction therapy was associated with a significantly higher perioperative but not worse long-term mortality compared to a left-sided procedure., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Donors with characteristics that may increase the likelihood of disease transmission with transplantation are noted as increased risk via Public Health Service criteria. This study aimed to establish the implications of declining an increased-risk donor (IRD) organ offer in lung transplantation., Methods: Adult candidates waitlisted for isolated lung transplantation in the United States using the Organ Procurement and Transplantation Network /United Network of Organ Sharing registry from 2007 to 2017 were identified. Individual match run files identified candidate recipients who matched to an IRD offer. Competing-risks analysis ascertained the likelihood of survival to transplantation. A stratified Cox model and restricted mean survival times estimated the survival benefit associated with the acceptance of an IRD organ., Results: A total of 6,963 candidates met inclusion criteria, and 1,473 (21.2%) accepted an IRD offer. Candidates who accepted an IRD offer were older, more likely to be male, and had a higher lung allocation score at the time of listing (all p < 0.05). At 1 year after an IRD offer decline, 70.5% of candidates underwent a lung transplant, 13.8% died or decompensated, and 14.9% were still awaiting transplant. Compared with those who declined, candidates who accepted the IRD offer had significantly improved cumulative mortality at 1 year (14.1% vs 23.9%, p < 0.001) and 5 years (48.4% vs 53.8%, p < 0.001)., Conclusions: IRD organ declination is associated with a decreased rate of lung transplantation and worse survival. Overall post-transplant survival rates for those who survive to transplantation are equivalent., (Copyright © 2018 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Historically, potential lung donors who have detectable antibodies to hepatitis C virus have been declined by most centers due to concern for possible disease transmission. We sought to evaluate hepatitis C viral transmission rates from donors who were known to be HCV Ab positive but HCV NAT negative. We performed a single-center retrospective review of a prospectively collected database for lung transplant recipients at our center including HCV Ab+NAT- donors (approved January 2017). Donor and recipient demographic data were compiled, and records were queried to ascertain rate of seroconversion. During the study period (1/1/17 to 8/9/17), a total of 64 recipients underwent lung transplantation. Thirteen (20%) donors were HCV Ab+NAT-. All recipients of HCV Ab+NAT- grafts were HCV Ab- at the time of transplant. Recipients of grafts from HCV Ab+NAT- donors underwent protocol NAT at 2 and 12 months and all are NAT- to date. One recipient developed reactive HCV Ab at 6 months post-transplant. Follow-up NAT showed HCV RNA to be undetectable. To date, use of HCV Ab+NAT- donors in lung transplantation has yielded favorable outcomes, with evidence of one transient seroconversion suggesting this practice may increase access to life-saving transplantation to those in need., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Although in situ internal mammary artery (is-IMA) grafting remains the most frequent conduit in coronary artery bypass grafting (CABG), circumstances may necessitate free grafting of the IMA (f-IMA), though differences in outcomes have not been fully characterized. The purpose of this study was to compare clinical and angiographic outcomes of is-IMA versus f-IMA coronary bypass grafts in patients who underwent elective CABG surgery. In 1,829 patients in the angiographic cohort of PREVENT IV, 1,572 (85.9%) had at least 1 IMA graft; of these, 34 (2.2%) patients had at least 1 f-IMA graft and 1,538 (97.8%) had at least 1 is-IMA graft without additional f-IMA grafts. Characteristics of patients, procedure, and grafts/targets were compared between cohorts. Primary endpoints included death, myocardial infarction, and revascularization, as well as incidence of graft failure (stenosis >75%) on angiography at 12-18 months postoperatively. Patients receiving is-IMA grafts were more often of white race and higher weight. Aortic cross-clamp time was shorter in the f-IMA cohort (39.5 vs 57.0 min, p = 0.04), but duration of bypass was similar (93.5 vs 100.0 minutes, p = 0.793). Of the in situ grafts, 97.3% were via the left internal mammary artery (LIMA), 86.6% were of good quality, and the left anterior descending (LAD) was bypassed in 88.2%. This compares with free grafts, which were via the LIMA in 68.0%, of good quality in 96.1%, and bypassed the LAD in 58.8% and first obtuse marginal (OM1) in 23.5%. Rates of death, myocardial infarction, and revascularization were similar between groups. The rate of graft failure was higher in f-IMA grafts (23.3%) compared with is-IMA grafts (8.5%; p < 0.01). Although clinical outcomes were similar with use of free versus in situ IMA grafts, higher rates of graft failure were encountered with use of the f-IMA graft. In conclusion, in situ grafts should be the preferred conduit for patients who undergo CABG surgery., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The purpose of this research is to study the early stages of the Senhance learning curve to report how force feedback impacts learning rate. This serves as an exploratory investigation into assumptions that fellows and faculty will adjust faster to the Senhance in comparison with residents, and that force feedback will not hinder skill acquisition., Design: In this study, participants completed the peg transfer and precision cutting task from the Fundamentals of Laparoscopic Surgery (FLS) manual skills assessment five times each using the Senhance while instrument motion was tracked., Setting: This study took place in the Surgical Education and Activities Laboratory at Duke University Medical Center., Participants: Participants for this study were residents, fellows, and faculty from Duke University Medical Center in general surgery and gynecology specialties (N = 16)., Results: Postulated linear mixed effects models with participant level random effects showed significant improvement with additional attempts for the peg transfer task after adjusting for surgical experience and force feedback respectively for the primary FLS score metric. The secondary metric of total instrument path length also showed improvement (significant decreases) in path length with additional attempts after respectively adjusting for surgical experience and force feedback., Conclusions: This study investigates the early stages of the learning curve of the Senhance. Exploratory modeling indicates that residents, fellows, and faculty surgeons rapidly adapt to the controls of the Senhance regardless of experience level and force feedback engagement. The results from this study may serve as motivation for future prospective studies that achieve sufficient statistical power with a larger sample size and strict experimental design., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Blood type O lung allografts may be allocated to blood type identical (type O) or compatible (non-O) candidates. We tested the hypothesis that the current organ allocation schema in the United States-based on the Lung Allocation Score-prejudices against the allocation of allografts to type O candidates, given that the pool of potential donors is smaller., Methods: We performed a retrospective cohort review of the Organ Procurement and Transplantation Network/United Network of Organ Sharing registry from May 2005 to March 2017 for adult candidates on the waiting list for first-time isolated lung transplantation. Demographic data were compiled and described, and 1:1 nearest-neighbor propensity score matching was used to adjust for age and Lung Allocation Score at listing., Results: A total of 26,396 candidates met inclusion criteria: 14,329 type non-O and candidates and 12,068 type O candidates. After matching, 11,951 candidates were included in each group. Of these, 77.0% of type non-O underwent lung transplantation vs 73.1% type O (p < 0.001). At 1 year, the waiting list mortality was higher for type O candidates (12.5%) than for non-O candidates (10.1%, p < 0.001). Of those undergoing transplantation, 5-year survival rates were similar., Conclusions: Type O candidates experience lower rates of transplantation and higher rates of waiting list mortality compared with matched type non-O candidates. Further evaluation of regional sharing of allografts to increase transplantation rates for type O candidates may be warranted to optimize equity in access to transplants., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The breadth of technical skills included in general surgery training continues to expand. The current competency-based training model requires assessment tools to measure acquisition, learning, and mastery of technical skill longitudinally in a reliable and valid manner. This study describes a novel skills assessment tool, the Omni, which evaluates performance in a broad range of skills over time., Design: The 5 Omni tasks, consisting of open bowel anastomosis, knot tying, laparoscopic clover pattern cut, robotic needle drive, and endoscopic bubble pop, were developed by general surgery faculty. Component performance metrics assessed speed, accuracy, and quality, which were scaled into an overall score ranging from 0 to 10 for each task. For each task, ANOVAs with Scheffé's post hoc comparisons and Pearson's chi-squared tests compared performance between 6 resident cohorts (clinical years (CY1-5) and research fellows (RF)). Paired samples t-tests evaluated changes in performance across academic years. Cronbach's alpha coefficient determined the internal consistency of the Omni as an overall assessment., Setting: The Omni was developed by the Department of Surgery at Duke University. Annual assessment and this research study took place in the Surgical Education and Activities Lab., Participants: All active general surgery residents in 2 consecutive academic years spanning 2015 to 2017., Results: A total of 62 general surgery residents completed the Omni and 39 (67.2%) of those residents completed the assessment in 2 consecutive years. Based on data from all residents' first assessment, statistically significant differences (p < 0.05) were observed among CY cohorts for bowel anastomosis, robotic, and laparoscopic task metrics. By pair-wise comparisons, mean bowel anastomosis scores distinguished CY1 from CY3-5 and CY2 from CY5. Mean robotic scores distinguished CY1 from RF, and mean laparoscopic scores distinguished CY1 from RF, CY3, and CY5 in addition to CY2 from CY3. Mean scores in performance on the knot tying and endoscopic tasks were not significantly different. Statistically significant improvement in mean scores was observed for all tasks from year 1 to year 2 (all p < 0.02). The internal consistency analysis revealed an alpha coefficient of 0.656., Conclusions: The Omni is a novel composite assessment tool for surgical technical skill that utilizes objective measures and scoring algorithms to evaluate performance. In this pilot study, 3 tasks demonstrated discriminative ability of performance by CY, and all 5 tasks demonstrated construct validity by showing longitudinal improvement in performance. Additionally, the Omni has adequate internal consistency for a formative assessment. These results suggest the Omni holds promise for the evaluation of resident technical skill and early identification of outliers requiring intervention., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution., Design: For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient., Setting: This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System., Participants: All active general surgery residents during the 2016-2017 academic year., Results: Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p < 0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038)., Conclusions: In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting., (Copyright © 2018. Published by Elsevier Inc.)

Background: Liver-lung transplantation (LLT) is a rare procedure performed for patients with end-stage liver and lung disease. The lung allocation score (LAS), introduced in 2005, guides lung allocation including those receiving LLT. However, the impact of the LAS on outcomes in LLT is currently unknown., Materials and Methods: The OPTN/United Network for Organ Sharing STAR file was queried for LLT candidates and recipients from 1988 to 2016. Demographic characteristics before (historic) and after (modern) the LAS were compared. Survival was analyzed with the Kaplan-Meier method and log-rank test., Results: In total, 167 candidates were listed for LLT, and 62 underwent LLT. The historic cohort had a higher FEV1% (48.22% versus 29.82%, P = 0.014), higher creatinine (1.22 versus 0.72, P < 0.001), and a higher percentage with pulmonary hypertension as the indication for transplantation (40% versus 0%, P = 0.003) compared with the modern cohort. LLT candidates in the historic cohort had a lower rate of transplant per 100 candidates (10.87 versus 33.33, P < 0.0001) and worse waitlist survival (1 y: 69.6% versus 80.9%, 3 y: 39.1% versus 66.8%, P = 0.004). Post-transplant survival was significantly lower in the historic cohort (1 y: 50.0% versus 82.7%, 5 y: 40.0% versus 69.0%, 10 y: 20.0% versus 55.5%, P = 0.0099)., Conclusions: Most analyses of LLT have included patients before and after the introduction of the LAS. Our study shows that LLT candidates and recipients before the modern allocation system had distinct baseline characteristics and worse overall survival. Although many factors contributed to recent improved outcomes, these cohorts are significantly different and should be treated as such in future studies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Lobar resection is the gold standard therapy for medically fit patients with stage I non-small cell lung cancer (NSCLC). However, considerable variability exists in the use of surgical therapy. This study tested the hypothesis that center-based variation in the use of surgical therapy affects survival in NSCLC., Methods: We queried the National Cancer Database for patients with stage I NSCLC. Mixed-effects multivariable models were developed to establish the per-center adjusted rate of surgical therapy. Patients were stratified into quartiles based on the treating center's adjusted rate of surgical therapy. Survival was estimated and then tested by using Kaplan-Meier and the log-rank test. Multivariable Cox proportional hazard models were developed to estimate the effect of rate of surgical therapy on overall survival., Results: A total of 139,802 patients met the criteria. There was wide variation in the per-center rate of surgical resection in the highest (80.8%) versus lowest (41.4%, p < 0.001) quartile. Across cohorts, patients were similar in age (mean 68.8 years in the highest quartile versus 69.7 in the lowest quartile) and Charlson-Deyo Score of 2 or greater (15.1% in the highest quartile versus 14.4% in the lowest quartile). Five-year survival was higher for patients treated at high-use centers (52.7% versus 36.7%, p < 0.001). After adjustment, an adjusted rate of surgical therapy in the lowest 25th percentile was associated with lower survival (adjusted hazard ratio 1.40, 95% confidence interval: 1.37 to 1.40, p < 0.001)., Conclusions: Treatment at a center with a higher rate of surgical therapy confers a considerable survival advantage, even after adjustment for hospital volume, surgical approach, and other confounders. Targeted efforts to improve adherence to guidelines about provision of surgical therapy in early-stage NSCLC may represent a meaningful opportunity to improve outcomes., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: National outcomes of robotic mitral valve repair (rMVr) compared with sternotomy (sMVr) in older patients are currently unknown., Methods: From 2011 to 2014, all patients aged 65 years and older undergoing MVr in The Society of Thoracic Surgeons Adult Cardiac Surgery Database linked to Medicare claims data were identified. Patients who underwent rMVr were propensity matched to patients who underwent sMVr. Standard differences and falsification outcome of baseline characteristics were tested to ensure a balanced match. Cox models were used to calculate 3-year mortality, heart failure readmission, and mitral valve reintervention, adjusting for competing risks where appropriate., Results: After matching, 503 rMVr patients from 65 centers and 503 sMVr from 251 centers were included. There were no significant differences in comorbidities or falsification outcome. Cardiopulmonary bypass and cross-clamp times were longer with rMVr versus sMVr at 125 versus 102 minutes (p < 0.0001) and 85 versus 75 minutes (p < 0.0001), respectively. The rMVr patients had shorter intensive care unit (27 vs 47 hours, p < 0.0001) and hospital stay (5 vs 6 days, p < 0.0001), less frequent transfusion (21% vs 35%, p < 0.0001), and less atrial fibrillation (28% vs 40%, p < 0.0001). Three-year mortality (hazard ratio, 1.21; 95% confidence interval, 0.68 to 2.16; p = 0.52), heart failure readmission (hazard ratio, 1.42; 95% confidence interval, 0.80 to 2.52, p = 0.10), and mitral valve reintervention (hazard ratio, 0.42; 95% confidence interval, 0.15 to 1.18; p = 0.22) did not differ between the groups., Conclusions: The rMVr procedure was associated with less atrial fibrillation, less frequent transfusion requirement, and shorter intensive care unit and hospital stay, without a significant difference in 3-year mortality, heart failure readmission, or mitral valve reintervention. In older patients, rMVr confers short-term advantages without a detriment to midterm outcomes., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Prior studies suggest underutilization of invasive mediastinal staging for lung cancer. We hypothesized that The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) participants would have higher rates of invasive staging compared with previous reports., Methods: We conducted a retrospective cohort study (2012 to 2016) of lung cancer patients staged by computed tomography and positron-emission tomography and first treated with an anatomic resection. We defined invasive staging by the use of mediastinoscopy, endosonography, or thoracoscopy. Standardized incidence ratios were used to compare participant-level rates of invasive staging, and Poisson regression was used to identify factors associated with invasive staging., Results: Among 29,015 patients across 256 participating STS-GTSD sites, 34% (95% confidence interval: 33% to 34%) underwent invasive staging. The overall rate of invasive staging did not change between 2012 and 2016 (p trend = 0.16). Increasing clinical stage and features suggestive of a central tumor were associated with invasive staging (p < 0.001). Rates of invasive staging among patients with clinical stage IB or greater or features suggestive of a central tumor were 43% (95% confidence interval: 42% to 44%) and 52% (95% confidence interval: 50% to 54%), respectively. There was a more than 40-fold variation in rates of invasive staging across 251 centers contributing at least 10 cases (standardized incidence ratio: lowest = 0.08; highest = 3.26); 66 sites (26%) performed invasive mediastinal staging less often than average and 77 sites (31%) performed invasive staging more often than average., Conclusions: The STS-GTSD participants performed invasive mediastinal staging more frequently than prior reports, and yet only in a minority of patients. Rates of invasive mediastinal staging vary widely across STS-GTSD participants., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Previous studies have demonstrated a 20% mortality rate among patients undergoing isolated coronary artery bypass grafting (CABG) for cardiogenic shock. However, outcomes following CABG for cardiogenic shock in patients who are neurologically unresponsive preoperatively are unknown., Methods: Utilizing the Society of Thoracic Surgeons Adult Cardiac Surgery Database between July 2011 and December 2013, patients undergoing urgent or emergent CABG within 7 days of an acute myocardial infarction complicated by cardiogenic shock were identified. Patients were stratified on the basis of whether they had a non-medically induced unresponsive state within 24 h of surgery., Results: Of the 5259 patients with acute myocardial infarction complicated by cardiogenic shock who underwent CABG during the study period, 243 (4.62%) patients had an unresponsive preoperative neurological state. The unresponsive cohort had a higher 30-day operative mortality than the responsive cohort (33.74% vs 16.91%, P < 0.001). Unresponsive neurological state was associated with increased odds for mortality (adjusted odds ratio 1.81, 95% confidence interval 1.37-2.4; P < 0.001), postoperative stroke (adjusted odds ratio 2.17, 95% confidence interval 1.27-3.73; P = 0.0048) and encephalopathy (adjusted odds ratio 2.08, 95% confidence interval 1.44-3.01; P < 0.001). Among survivors in the unresponsive cohort, 78 (46.15%) were discharged home and 62 (36.69%) were discharged to extended care facilities., Conclusions: Although cardiac surgery in unresponsive patients in the setting of acute myocardial infarction complicated by cardiogenic shock is associated with considerable neurological disability and mortality, the majority survive to discharge. These findings may help guide patient and family discussions regarding goals of care.