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Anal cancer, though rare, is witnessing an annual increase in incidence, predominantly of squamous cell carcinoma (SCC). Prevention strategies revolve around reducing risk factors such as human papillomavirus (HPV) infection, human immunodeficiency virus/acquired immunodeficiency syndrome, immunosuppression, smoking, and high-risk sexual practices, while advocating for HPV vaccination. The Anal Cancer-HSIL Outcomes Research trial validates treating anal high-grade squamous intraepithelial lesion to curb SCC development. Screening methods include digital anal rectal examination, anal Papanicolaou smear, HPV testing, and high-resolution anoscopy. However, standardized screening guidelines are lacking, necessitating future efforts to streamline protocols and enhance public awareness of anal cancer., Competing Interests: Disclosure Neither authors have financial nor relevant disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Sociodemographic disparities in colorectal cancer (CRC) surgical patients are known. Few studies, however, have examined the intersection of insurance type and median household income (MHI)., Methods: In this retrospective analysis of the National Inpatient Sample from 2000 to 2019, all CRC surgery patients between 50 and 64 y old were included. Patients were further stratified based on insurance type (commercial, Medicaid, and uninsured) as well as county-level MHI quartiles. Outcomes included nonelective surgery (primary outcome), inpatient mortality, complications, and blood transfusions. Multivariate logistic regression adjusted for sociodemographic variables, medical comorbidities, and hospital-level factors., Results: Of 108,606 patients, 80.5% of patients had commercial insurance, while 5.8% were uninsured. On multivariate analysis, Medicaid or no insurance, especially when living in a lower-income community, were associated with significantly higher odds of nonelective surgery (ORs: 1.11-4.54). There was a stepwise effect on nonelective surgery by insurance type (uninsured with lower odds than insured) and MHI (each lower quartile had higher odds). There were similar trends for inpatient blood transfusions, but there were no significant differences in mortality or complications., Conclusions: Especially when considered together, noncommercial insurance and lower MHI were associated with worse outcomes in CRC patients. Insurance was more protective than MHI against worse outcomes. These findings among a screening-aged cohort have policy planning implications for insurance expansions and healthcare funding allocations. Further research is needed to understand the complex underlying mechanisms that create this interaction between insurance and MHI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background/Objectives: Colorectal cancer remains a significant global health challenge, particularly in resource-limited settings where patient-centered outcomes following surgery are often suboptimal. Although more prevalent in low- and middle-income countries (LMICs), segments of the United States have similarly limited healthcare resources, resulting in stark inequities even within close geographic proximity. Methods: This review compares and contrasts colorectal cancer outcomes in LMICs with those in resource-constrained communities in rural America, utilizing an established implementation science framework to identify key determinants of practice for delivering high-quality colorectal cancer care. Results : Barriers and innovative, community-based strategies aimed at improving patient-centered outcomes for colorectal cancer patients in low resource settings are identified. We explore innovative approaches and community-based strategies aimed at improving patient-centered outcomes, highlighting the newly developed colorectal surgery fellowship in Sub-Saharan Africa as a model of innovation in this field. Conclusions: By exploring these diverse contexts, this paper proposes actionable solutions and strategies to enhance surgical care of colorectal cancer and patient outcomes, ultimately aiming to inform global health practices, inspire collaboration between LMIC and rural communities, and improve care delivery across various resource settings.

Introduction: An intestinal stoma creation is one of the most common surgical procedures. Despite benefits, a stoma can have serious effects on a patient's quality of life. Multiple dimensions of everyday life can be affected such as social life, body image, as well as ability to participate in some religious practices, with some faith groups being disproportionately affected. This study sought to understand the extent to which faith is addressed during these sessions given the integral role it plays for some patients., Methods: A survey was developed based on literature review and expert consultation. This was distributed to ostomy certified nursing staff, inflammatory bowel disease gastroenterologists and colorectal surgeons caring for patients requiring a permanent stoma at a high-volume academic institution. Follow-up semistructured interviews were conducted to delve deeper into themes identified in the surveys., Results: The overall survey response rate was 57%. Only 35% reported training on how stomas interface with religious practices. Religious services were either rarely or never present during preoperative counseling discussions. During interviews, it was noted that religious beliefs often impact after care but are not always discussed during preoperative sessions. Interviewees found these conversations to be difficult with minimal support or direction on how to navigate them., Conclusions: Although very important, health-care providers are not including faith-based issues surrounding stomas in perioperative counseling partly due to lack of training or awareness of existing support systems. As our population diversifies, understanding cultural and religious practices that influence care is increasingly important., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Given the rapidly changing landscape of residency applications, many medical students struggle to identify guidance from faculty advisors. Additionally, faculty advisors may find it difficult to maintain up-to-date knowledge on changes such as the new supplemental application. These gaps could potentially lead to inequitable advising. The objective of this study was to identify both students' and faculty's perceived barriers and expectations for residency application advising., Methods: Anonymous surveys were administered to both fourth-year medical students and faculty advisors at a single institution within 2 mo of the residency application deadline. Survey questions assessed student and faculty barriers to establishing the advisor-advisee relationships, as well as expectations of the advisor role. Surveys were analyzed using descriptive statistics., Results: We identified that the majority of students (57%) did not have a faculty advisor within weeks of the application deadline, and an equal amount felt that finding an advisor was either somewhat difficult or extremely difficult. Of all the students, 60% felt their biggest barrier was not knowing how to find an advisor. Though faculty felt equipped to advise students, 75% of faculty in the participating specialties had advising concerns regarding the supplemental application or were unaware of the changes., Conclusions: We identified gaps in the residency application advising process from both student and faculty perspectives. Future work involves increasing awareness of the resources and opportunities available to students to improve advising relationships. Standardized training tools and resources for faculty will result in more consistent and reliable faculty advising., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Efforts to improve physician well-being have focused on gratitude, which predicts health and happiness. Despite reported benefits, expressions of gratitude in healthcare can seem infrequent. Here, we describe Gratitude-Grams, an intervention to cultivate expressions of gratitude throughout a department., Methods/approach: Piloted in our Department of Surgery and adopted by others, Gratitude-Grams employs a web-based platform (Qualtrics). Program feedback was solicited during teaching conferences using an anonymous department survey., Results: Gratitude-Grams streamlines and encourages expressions of gratitude while minimizing maintenance, cost, and time. The platform has been highly utilized and well-received in our Department of Surgery., Conclusion: Expressing and receiving gratitude has been shown to be critical for well-being. Gratitude-Grams is a highly utilized, simple, and attainable system to support expressions of gratitude and is ready for rapid implementation., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The operating room (OR) is a complex environment for medical students. Little is known about the OR staff's perception of medical students., Methods: We utilized an embedded mixed methods design to characterize surgical staff perceptions of students at an academic institution. We surveyed 408 OR nursing/technician staff with 16 follow-up interviews., Results: 139 respondents. 91.3% reported having daily-to-weekly interactions with medical students. Yet, only 37.9% agreed that "patient care is better when medical students are part of the team." 25.2% felt confident that they knew what a student's education entails outside the OR. 93.5% agreed that interprofessional training between physicians and OR staff should be included in educational programs. 54% agreed that their responsibilities include medical student training in the OR setting., Conclusions: Despite an overall desire for teamwork, this study highlights a lack of knowledge of each others' roles. To improve OR culture and team dynamics, concerted efforts need to be made around interprofessional training., Competing Interests: Declaration of competing interest The authors of the manuscript “Elucidating Academic Surgical Staff Perspectives of Medical Student Learning in the Operating Room: An Embedded Mixed Methods Study” have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Despite increasing female representation in U.S. medical schools, women remain underrepresented in academic surgery departments across the country. Even as the gap narrows in academic surgery, female surgeons' professional advancement does not parallel that of their male counterparts. This article explores how to continue to advance women in academic surgery, first by considering the barriers women surgeons face, then offering actionable steps-on the individual, interpersonal, and systems levels-to overcome these barriers and work toward gender equity., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Introduction: It is well documented that medical students who identify as underrepresented in medicine are more likely to encounter social challenges in the clinical environment. Successful navigation of these challenges requires a social and emotional agility that is unmeasured in traditional metrics of success. The effects of this requirement has not yet been explored. The authors therefore set out to investigate the variations in experiences that exist between underrepresented minority students in medicine (URiM) and white students, and to determine if there was a difference in the quantitative performance evaluations applied to both groups of students., Methods: This was a mixed-methods study. In the quantitative portion, the authors retrospectively analyzed the standardized patient encounter scores of medical students from a single medical school in Michigan during the years of 2016 to 2018. The authors used multivariable ordinary least squares regression models to evaluate the differences in scores by race. In the qualitative portion, students volunteered to be interviewed and self-identified their race and gender. The authors employed semi-structured interview techniques to gather information about how the student felt their cultural or ethnic background affected their experience in the clinical environment., Results: For the quantitative portion of this study, the authors analyzed the scores of 534 students over 4 different standardized patient encounters. The average score across all 4 standardized patient encounters was 88.7 (SD=5.6). The average score across all 4 standardized patient encounters for white students was 89 (SD=5.3), Black 87.9 (SD=7.4) Twenty-four students participated in the semi-structured interviews. Participants described feeling that the way their assessors interacted with them was largely affected by their race or gender. They also described feeling tension between how they would usually express themselves and how they were expected to in the clinical environment. When probed further, participants described various methods of adaptation to this tension including changing their hair or natural style of speech and modifying their perception of their role in the clinical environment., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment., Background: Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large., Methods: Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment., Results: There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (β = 0.504, 95% CI: 0.341-0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (β = 0.178, 95% CI: 0.153-0.203)., Conclusions: Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Timely colorectal cancer (CRC) screening has been shown to improve CRC-related morbidity and mortality rates. However, even with this preventative care tool, CRC screening rates remain below 70% among eligible United States (US) adults, with even lower rates among US immigrants. The aim of this scoping review is to describe the barriers to CRC screening faced by this unique and growing immigrant population and discuss possible interventions to improve screening., Methods: Four electronic databases were systematically searched for all original research articles related to CRC screening in US immigrants published after 2010. Following a full-text review of articles for inclusion in the final analysis, data extraction was conducted while coding descriptive themes. Thematic analysis led to the organization of this data into five themes., Results: Of the 4637 articles initially identified, 55 met inclusion criteria. Thematic analysis of the barriers to CRC screening identified five unique themes: access, knowledge, culture, trust, health perception, and beliefs. The most cited barriers were in access (financial burden and limited primary care access) and knowledge (CRC/screening knowledge)., Conclusions: US immigrants face several barriers to the receipt of CRC screening. When designing interventions to increase screening uptake among immigrants, gaps in physician and screening education, access to care, and trust need to be addressed through culturally sensitive supports. These interventions should be tailored to the specific immigrant group, since a one-size-fits approach fails to consider the heterogeneity within this population., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To prioritize trainee well-being, promote professionalism, and allow individuals to raise concerns without fear of retribution, one surgical department created an innovative process by which individuals can raise concerns and obtain subsequent support., Design and Setting: The University of Michigan Department of Surgery implemented the Michigan Action Progress System (MAPS) in February 2021., Participants: General Surgery residents, faculty, and staff voluntarily participate in MAPS., Results: Since implementation, there have been 26 entries into MAPS. Petitioners included students (10, 38%), residents and fellows (7, 27%), staff (1, 4%), faculty (1, 4%), and anonymous petitioners (7, 27%). Concerns regarding racism (1, 4%), bullying (11, 52%), gender discrimination (1, 4%), and other incidents (8, 38%) were addressed though MAPS., Conclusions: We have successfully implemented an innovative system that focuses on the needs of the user, consolidates handling of concerns, and emphasizes transparency, documentation, education, and improvement to promote a culture of professionalism and accountability., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Skin-bleaching is a common practice globally and is associated with many cutaneous and systemic health risks. Anecdotally, skin-bleaching is linked to impairments in wound healing, but there are little data to support the claim. This cross-sectional survey of health care professionals serving the Greater Accra Region, Ghana region investigates their observations of wound healing in patients who skin-bleach and their methods for screening skin-bleach use in patients. A 25-item self-administered questionnaire using 5-point Likert scale was distributed with convenient sampling to physicians and nurses employed at Ghanaian hospitals. Fifty-seven electronic and 78 paper responses were collected (total = 135). Most respondents agreed that wounds in skin-bleaching patients heal more slowly (4.22), are more prone to infection (4.11), haemorrhage (3.89), wound dehiscence (3.9), and are more difficult to manage (4.13). No respondent reported universal screening of all patients for skin-bleaching, but most ask about skin-bleaching if there is suspicion of it (42.2%). Our findings support the anecdotes about observable wound healing impairments in patients who skin-bleach. There is also wide variation in skin-bleaching screening practices, suggesting a need for guidelines to properly identify these patients and facilitate early risk prevention., (© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Objective: To examine the alignment between graduating surgical trainee operative performance and a prior survey of surgical program director expectations., Background: Surgical trainee operative training is expected to prepare residents to independently perform clinically important surgical procedures., Methods: We conducted a cross-sectional observational study of US general surgery residents' rated operative performance for Core general surgery procedures. Residents' expected performance on those procedures at the time of graduation was compared to the current list of Core general surgery procedures ranked by their importance for clinical practice, as assessed via a previous national survey of general surgery program directors. We also examined the frequency of individual procedures logged by residents over the course of their training., Results: Operative performance ratings for 29,885 procedures performed by 1861 surgical residents in 54 general surgery programs were analyzed. For each Core general surgery procedure, adjusted mean probability of a graduating resident being deemed practice-ready ranged from 0.59 to 0.99 (mean 0.90, standard deviation 0.08). There was weak correlation between the readiness of trainees to independently perform a procedure at the time of graduation and that procedure's historical importance to clinical practice ( p = 0.22, 95% confidence interval 0.01-0.41, P = 0.06). Residents also continue to have limited opportunities to learn many procedures that are important for clinical practice., Conclusion: The operative performance of graduating general surgery residents may not be well aligned with surgical program director expectations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the research and career interests of aspiring academic surgeons and determine the influence of demographic factors., Design: Cross-sectional survey SETTING: Single institution, academic general surgery residency program PARTICIPANTS: Medical students invited to interview during 2019-2020 and 2020-2021 residency cycle RESULTS: One hundred fifty-four of 160 (96%) potential respondents representing 63 medical schools completed the survey, American Association for Public Opinion Research Response Rate 6. Fifty-three percent of the study population was female. Seventeen percent identified as Black, 14% Asian, 13% Latinx, 50% white, and 6% other. Respondents were most interested in education, professional development, and surgical culture (32%) followed by basic and translational science (23%), global and community health (20%), and health services (18%). On multiple logistic regression, interest in global/community health was associated with identifying as Black (OR 5.9 [2.0, 17.8] p = 0.001) and female (OR 2.7 [1.0, 7.0] p = 0.044). A plurality of participants were undecided on future specialty (n = 63, 41%). The most common specialty interests were surgical oncology (n = 28, 18%); trauma, acute care, or surgical critical care (n = 21, 14%); pediatric and cardiothoracic surgery (n = 20 for each, 13%); and abdominal transplant (n = 15, 10%)., Conclusions: In this cross-sectional survey of highly competitive academic general surgery applicants, respondents who were underrepresented in medicine (URiM) and women were more interested in research fields with a history of lower relative NIH funding. In light of these findings, academic programs seeking a more diverse residency workforce should consider strategies beyond recruitment to promote the scholarly achievement of women and URiM residents., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The taxing nature of surgery residency is well-documented in the literature, with residents demonstrating high rates of burnout, depression, suicidal thoughts, sexual harassment, and racial discrimination. Mentoring has been shown to improve camaraderie, address challenges of underrepresentation in medicine, and be associated with lower burnout. However, existing formal mentoring programs tend to be career-focused and hierarchal without opportunity to discuss important sociocultural issues. An innovative approach is needed to address these cultural and anthropological issues in surgery residencies while creating camaraderie and learning alternative perspectives across different levels of training. We sought to describe the framework we used to fill these needs by creating and implementing a novel mentoring program., Design: A vertical, near-peer mentoring system of 7 groups was created consisting of the following members: 1 to 2 medical students, a PGY-1 general surgery resident, a PGY-4 research resident, and a faculty member. Meetings occur every 3 to 4 months in a casual setting with the first half of the meeting dedicated to intentional reflection and the second half focused on an evidence-based discussion regarding a specific topic in the context of surgery (i.e., burnout, discrimination, allyship, and finding purpose)., Setting: Program implementation took place at the University of Michigan in Ann Arbor, MI., Participants: Medical students, general surgery residents, and general surgery faculty were recruited., Conclusions: We have successfully launched the pilot year of a cross-spectrum formal mentoring program in general surgery. This program emphasizes camaraderie throughout training while providing opportunities for evidence-based discussion regarding sociocultural topics. We have included increased opportunities for community inclusivity and mentoring while allowing trainees and faculty members to discuss sensitive topics in a supportive environment. We plan to continue developing the program with robust evaluation and to expand the program to other surgical specialties and to other institutions., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mary R. Shen, MD, MS is supported by the Health Services Research Training Program (NIH T32HS00053). Kerry Madison, MD is supported by the Surgical Oncology Training Program T32 (NIH 5T32CA009672-30), Brooke C. Bredbeck, MD - Dr. Bredbeck is supported by the Ruth L. Kirschstein Research Service Award from the National Cancer Institute (NCI; T32 CA009672). Michael T. Kemp, MD – No disclosures to report. Jessica R. Santos-Parker, MD, PhD – No disclosures to report. Gurjit Sandhu, PhD - No disclosures to report. Brian C. George, MD, MAEd - No disclosures to report. Paul Gauger, MD – No disclosures to report. David T. Hughes, MD – No disclosures to report. Justin B. Dimick, MD, MPH – Dr. Dimick is supported by the following grants: Using Video Analysis to Improve Outcomes of Laparoscopic Colectomy: National Institute of Health R01HS025365; Long-Term Comparative Effectiveness of Sleeve Gastrectomy: National Institute of Health R01DK115408. He is the co-founder of ArborMetrix, Inc, a venture-capital backed healthcare software company focused on measuring and improving hospital quality and cost-efficiency. He is a consultant for US News and World Report, Medicare Payment Advisory Commission, American College of Surgeons, and The Leapfrog Group. Gifty Kwakye, MD, MPH – No disclosures to report., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: We declare no competing interests.

Competing Interests: Competing interests: AGS has consulted for and received research funding from Exact Sciences. AR serves as member for Voxel Analytics and consults for Genophyll and Pact&Health. GHS is a founder of Anza Biotechnologies.

Background: Many US general surgery residents are interested in global surgery, but their competence with key procedures is unknown., Methods: Using a registry managed by the Society for Improving Medical Professional Learning (SIMPL), we extracted longitudinal operative performance ratings data for a national cohort of US general surgery residents. Operative performance at the time of graduation was estimated via a Bayesian generalized linear mixed model., Results: Operative performance ratings for 12,976 procedures performed by 1584 residents in 52 general surgery programs were analyzed. These spanned 17 of 31 (55%) procedures deemed important for global surgical practice. For these procedures, the probability of a graduating resident being deemed competent to perform a procedure was 0.95 (95% confidence interval 0.86-1.00) but was less than 0.9 for 3 observed procedures., Conclusion: Our results highlight gaps in the preparedness of US general surgery trainees to perform procedures deemed most important for global surgery settings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery., Methods: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies., Results: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access., Conclusion: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Importance: The reporting of race provides transparency to the representativeness of data and helps inform health care disparities. The International Committee of Medical Journal Editors (ICMJE) developed recommendations to promote quality reporting of race; however, the frequency of reporting continues to be low among most medical journals., Objective: To assess the frequency as well as quality of race reporting among publications from high-ranking broad-focused surgical research journals., Design, Setting, and Participants: A literature review and bibliometric analysis was performed examining all human-based primary research articles published in 2019 from 7 surgical journals: JAMA Surgery, Journal of the American College of Surgeons, Annals of Surgery, Surgery, American Journal of Surgery, Journal of Surgical Research, and Journal of Surgical Education. The 5 journals that stated they follow the ICMJE recommendations were analyzed against the 2 journals that did not explicitly claim adherence., Main Outcomes and Measures: Measured study outcomes included race reporting frequency and use of the ICMJE recommendations for quality reporting of race., Results: A total of 2485 publications were included in the study. The mean (SD) frequency of reporting of race and ethnicity in publications of ICMJE vs non-ICMJE journals was 32.8% (8.4) and 32.0% (20.9), respectively (P = .72). Adherence to ICMJE recommendations for reporting race was more frequent in ICMJE journals than non-ICMJE journals (mean [SD] of 73.1% [17.8] vs 37.0% [10.2]; P < .001)., Conclusions and Relevance: The frequency of race and ethnicity reporting among surgical journals is low. A journal's statement of adherence to ICMJE recommendations did not affect the frequency of race and ethnicity reporting; however, there was an increase in the use of ICMJE quality metrics. These findings suggest the need for increased and more standardized reporting of racial and ethnic demographic data among surgical journals.

Background: To focus on critical care needs of coronavirus patients, elective operations were postponed and selectively rescheduled. The effect of these measures on patients was unknown. We sought to understand patients' perspectives regarding surgical care during the CoVID-19 pandemic to improve future responses., Methods: We performed qualitative interviews with patients whose operations were postponed. Interviews explored patient responses to: 1) surgery postponement; 2) experience of surgery; 3) impacts of rescheduling/postponement on emotional/physical health; 4) identifying areas of improvement. Interviews were recorded, transcribed, coded, and analyzed through an integrated approach., Results: Patient perspectives fell within the following domains: 1) reactions to surgery postponement/rescheduling; 2) experience of surgery during CoVID-19 pandemic; 3) reflections on communication; 4) patient trust in surgeons and healthcare., Conclusions: We found no patient-reported barriers to rescheduling surgery. Several areas of care which could be improved (communication). There was an unexpected sense of trust in surgeons and the hospital., Competing Interests: Declaration of competing interest No conflicts of interest, use of off-label or unapproved drugs or products, or use of previously copyrighted material., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Underrepresented minority (URM) medical students face many educational challenges. Barriers include lack of equitable representation, scarce mentorship, and the effects of systemic racism. For students interested in diversity and health equity, perceptions of surgical culture may discourage pursuing surgical specialties. We describe a national pilot for a novel surgical pipeline program, Leadership Exposure for the Advancement of Gender and Underrepresented Minority Equity in Surgery (LEAGUES), which utilizes early exposure, mentorship, and community building to empower URM students in pursuit of academic surgical careers., Design: A 4-week virtual program included pairing students with faculty research mentors, virtual skills sessions, and seminars on leadership, advocacy, and career development. Participants underwent semi-structured interviews before and after participation, assessing experiences with mentorship and research, interest in surgery, career aspirations, and perceived barriers to career goals., Setting: Department of Surgery, Michigan Medicine, Ann Arbor, Michigan., Participants: Rising second-year medical students., Results: All 3 participants were Latinx; 2 were first-generation college students. Participants had no surgical mentorship and limited research exposure, citing a desire to learn research methodology, connect with mentors, and build towards a career working with underserved communities as motivating factors for participation. Perceived barriers to a surgical career included surgical culture, burnout, and lack of research expertise or academic network necessary for success. At completion of the program, participants described several themes: (1) new positive perspective on academic surgical culture, (2) interest and confidence in research, (3) hope for improving health disparities, (4) networking and longitudinal mentorship connections contributing to a sense of surgical community, and (5) eagerness to share resources with colleagues at their home institutions., Conclusions: LEAGUES program participants acquired tools and motivation to pursue careers in surgery, and established valuable longitudinal network and mentor relationships. LEAGUES is a novel model for national surgical pipeline programs., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice., Methods: Patients from the US Rectal Cancer Consortium (2007-2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge., Results: Of 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar., Conclusions: Although not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary., (© 2020. The Society for Surgery of the Alimentary Tract.)

Objective: In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency., Design: This was a retrospective observational cohort study. Attending ratings of residents' intraoperative performance were collected with the System for Improving and Measuring Procedural Learning application from 9/2015 to 9/2018. Descriptive analyses and Bayesian mixed models were used to determine a resident's probability of being deemed competent upon graduating residency, controlling for core vs. advanced procedure, case complexity, and rater and resident effects., Setting: Faculty and residents within 30 teaching institutions within the Procedural Learning and Safety Collaborative (PLSC)., Patients: We sampled colorectal procedures and categorized them as core or advanced based on American Board of Surgery designations., Results: A total of 564 residents were rated after 2102 operations (82% core, 18% advanced). A resident in their fifth year of clinical training had a 93% (95% CI 85-97%) adjusted probability of competent performance after a core procedure and 75% (95% CI 55-89%) after an advanced procedure., Conclusions: General surgery residents were not universally deemed competent to perform colorectal procedures even at the end of residency. These gaps were more pronounced for advanced colorectal procedures. Current graduation requirements should be carefully reviewed to ensure residents are appropriately trained to meet the needs of their communities. Additionally, advanced training remains a critical resource for surgeons who will perform complex colorectal procedures in practice., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Ghana has seen a rise in the incidence of colorectal cancer (CRC) over the past decade. In 2011, the Ghana National Cancer Steering Committee created a guideline recommending fecal occult blood testing (FOBT) for CRC screening in individuals over the age of 50. There is limited data available on current Ghanaian CRC screening trends and adherence to the established guidelines., Methods: We conducted a survey of 39 physicians working at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. The survey evaluates physician knowledge, practice patterns, and perceived personal-, patient- and system-level barriers pertaining to CRC screening., Results: Almost 10% of physicians would not recommend colorectal cancer screening for asymptomatic, average risk patients who met the age inclusion criteria set forth in the national guidelines. Only 1 physician would recommend FOBT as an initial screening test for CRC. The top reasons for not recommending CRC screening with FOBT were the lack of equipment/facilities for the test (28.1%) and lack of training (18.8%). The two most commonly identified barriers to screening identified by >85% of physicians, were lack of awareness of screening/not perceiving colorectal cancer as a serious health threat (patient-level) and high screening costs/lack of insurance coverage (system-level)., Conclusion: Despite creation of national guidelines for CRC screening, there has been low uptake and implementation. This is due to several barriers at the physician-, patient- and system-levels including lack of resources and physician training to follow-up on positive screening results, limited monetary support and substantial gaps in knowledge at the patient level.

Rectal prolapse frequently occurs in conjunction with functional and anatomic abnormalities of the bowel and pelvic floor. Prolapse surgery should have as its goal not only to correct the prolapse, but also to improve function to the greatest extent possible. Careful history-taking and physical exam continue to be the surgeon's best tools to put rectal prolapse in its functional context. Physiologic testing augments this and informs surgical decision-making. Defecography can identify concomitant middle compartment prolapse and pelvic floor hernias, potentially targeting patients for urogynecologic consultation or combined repair. Other tests, including manometry, ultrasound, and electrophysiologic testing, may be of utility in select cases. Here, we provide an overview of available testing options and their individual utility in rectal prolapse., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background: Local excision of T1 rectal cancers helps avoid major surgery, but the frequency and pattern of recurrence may be different than for patients treated with total mesorectal excision., Objective: This study aims to evaluate pattern, frequency, and means of detection of recurrence in a closely followed cohort of patients with locally excised T1 rectal cancer., Design: This study is a retrospective review., Settings: Patients treated by University of Minnesota-affiliated physicians, 1994 to 2014, were selected., Patients: Patients had pathologically confirmed T1 rectal cancer treated with local excision and had at least 3 months of follow-up., Interventions: Patients underwent local excision of T1 rectal cancer, followed by multimodality follow-up with physical examination, CEA, CT, endorectal ultrasound, and proctoscopy., Main Outcome Measures: The primary outcomes measured were the presence of local recurrence and the means of detection of recurrence., Results: A total of 114 patients met the inclusion criteria. The local recurrence rate was 11.4%, and the rate of distant metastasis was 2.6%. Local recurrences occurred up to 7 years after local excision. Of the 14 patients with recurrence, 10 of the recurrences were found by ultrasound and/or proctoscopy rather than by traditional methods of surveillance such as CEA or imaging. Of these 10 patients, 4 had an apparent scar on proctoscopy, and ultrasound alone revealed findings concerning for recurrent malignancy. One had recurrent malignancy demonstrated on ultrasound, but no concurrent proctoscopy was performed., Limitations: This was a retrospective review, and the study was conducted at an institution where endorectal ultrasound is readily available., Conclusions: Locally excised T1 rectal cancers should have specific surveillance guidelines distinct from stage I cancers treated with total mesorectal excision. These guidelines should incorporate a method of local surveillance that should be extended beyond the traditional 5-year interval of surveillance. An ultrasound or MRI in addition to or instead of flexible sigmoidoscopy or proctoscopy should also be strongly considered. See Video Abstract at http://links.lww.com/DCR/A979. CÁNCERES RECTALES T1 EXTIRPADOS LOCALMENTE: NECESIDAD DE PROTOCOLOS DE VIGILANCIA ESPECIALIZADOS: La escisión local de los cánceres de recto T1 ayuda a evitar una cirugía mayor, pero la frecuencia y el patrón de recurrencia pueden ser diferentes a los de los pacientes tratados con escisión mesorectal total., Objetivo: Evaluar el patrón, la frecuencia y los medios de detección de recidiva en una cohorte de pacientes con cáncer de recto T1 extirpado localmente bajo un régimen de seguimiento especifico. DISEÑO:: Revisión retrospectiva., Ajustes: Pacientes tratados por hospitales afiliados a la Universidad de Minnesota, 1994-2014 PACIENTES:: Pacientes con cáncer de recto T1 confirmado patológicamente, tratados con escisión local y con al menos 3 meses de seguimiento., Intervenciones: Extirpación local del cáncer de recto T1, con un seguimiento multimodal incluyendo examen físico, antígeno carcinoembrionario (CEA), TC, ecografía endorrectal y proctoscopia., Principales Medidas De Resultado: Presencia de recurrencia local y medios de detección de recurrencia., Resultados: Un total de 114 pacientes cumplieron con los criterios de inclusión. La tasa de recurrencia local fue del 11,4% y la tasa de metástasis a distancia fue del 2,6%. Las recurrencias locales se presentaron hasta 7 años después de la escisión local. De los 14 pacientes con recurrencia, 10 de las recurrencias se detectaron por ultrasonido y / o proctoscopia en lugar de los métodos tradicionales de vigilancia, como CEA o imágenes. De estos diez pacientes, cuatro tenían una cicatriz aparente en la proctoscopia y el ultrasonido solo reveló hallazgos relacionados con tumores malignos recurrentes. En una ecografía se demostró malignidad recurrente, pero no se realizó proctoscopia concurrente., Limitaciones: Revisión retrospectiva; estudio realizado en una institución donde se dispone fácilmente de ultrasonido endorrectal CONCLUSIONES:: Los cánceres de recto T1 extirpados localmente deben tener una vigilancia específica distinta de los cánceres en etapa I tratados con TME. El régimen de seguimiento deberá de extender más allá del intervalo tradicional de 5 años de vigilancia. También se debe considerar la posibilidad de realizar una ecografía o una resonancia magnética (IRM) además de la sigmoidoscopía flexible o la proctoscopía. Vea el Resumen del video en http://links.lww.com/DCR/A979.

Objective: This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation., Background: Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability., Methods: We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes., Results: We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy., Conclusion: Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.

Importance: Although family priorities influence specialty selection and resident attrition, few studies describe resident perspectives on pregnancy during surgical training., Objective: To directly assess the resident experience of childbearing during training., Design, Setting, and Participants: A self-administered 74-question survey was electronically distributed in January 2017 to members of the Association of Women Surgeons, to members of the Association of Program Directors in Surgery listserv, and through targeted social media platforms. Surgeons who had 1 or more pregnancies during an Accreditation Council for Graduate Medical Education-accredited US general surgery residency program and completed training in 2007 or later were included. Important themes were identified using focus groups of surgeons who had undergone pregnancy during training in the past 7 years. Additional topics were identified through MEDLINE searches performed from January 2000 to July 2016 combining the keywords pregnancy, resident, attrition, and parenting in any specialty., Main Outcomes and Measures: Descriptive data on perceptions of work schedule during pregnancy, maternity leave policies, lactation and childcare support, and career satisfaction after childbirth., Results: This study included 347 female surgeons (mean [SD] age, 30.5 [2.7] years) with 452 pregnancies. A total of 297 women (85.6%) worked an unmodified schedule until birth, and 220 (63.6%) were concerned that their work schedule adversely affected their health or the health of their unborn child. Residency program maternity leave policies were reported by 121 participants (34.9%). A total of 251 women (78.4%) received maternity leave of 6 weeks or less, and 250 (72.0%) perceived the duration of leave to be inadequate. The American Board of Surgery leave policy was cited as a major barrier to the desired length of leave by 268 of 326 respondents (82.2%). Breastfeeding was important to 329 (95.6%), but 200 (58.1%) stopped earlier than they wished because of poor access to lactation facilities and challenges leaving the operating room to express milk. Sixty-four women (18.4%) had institutional support for childcare, and 231 (66.8%) reported a desire for greater mentorship on integrating a surgical career with motherhood and pregnancy. A total of 135 (39.0%) strongly considered leaving surgical residency, and 102 (29.5%) would discourage female medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training., Conclusions and Relevance: The challenges of having children during surgical residency may have significant workforce implications. A deeper understanding is critical to prevent attrition and to continue recruiting talented students. This survey characterizes these issues to help design interventions to support childbearing residents.

Purpose: Providing resident autonomy in the operating room (OR) is one of the major challenges for surgical educators today. The purpose of this study was to explore what approaches expert surgical teachers use to assess residents' readiness for autonomy in the OR. We particularly focused on the assessments that experts make prior to conducting the surgical time-out., Methods: We conducted semistructured in-depth interviews with expert surgical teachers from March 2016 to September 2016. Purposeful sampling and snowball sampling were applied to identify and recruit expert surgical teachers from general surgery residency programs across the United States to represent a range of clinical subspecialties. All interviews were audio-recorded, deidentified, and transcribed. We applied the Framework Method of content analysis, discussed and reached final consensus on the themes., Results: We interviewed 15 expert teachers from 9 institutions. The majority (13/15) were Program or Associate Program Directors; 47% (7/15) primarily performed complex surgical operations (e.g., endocrine surgery). Five themes regarding how expert surgical teachers determine residents' readiness for OR autonomy before the surgical time-out emerged. These included 3 domains of evidence elicited about the resident (resident characteristics, medical knowledge, and beyond the current OR case), 1 variable relating to attending characteristics, and 1 variable composed of contextual factors. Experts obtained one or more examples of evidence, and adjusted residents' initial autonomy using factors from the attending variable and the context variable., Conclusions: Expert surgical teachers' assessments of residents' readiness for OR autonomy included 5 key components. Better understanding these inputs can contribute to both faculty and resident development, enabling increased resident autonomy and preparation for independent practice., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Traditionally, surgical training has used an apprenticeship model but has more recently moved to a service-based model, with groups of residents working with groups of attending surgeons. We developed an apprenticeship rotation to enhance one-on-one interaction between chief residents and selected faculty. We hypothesized that the apprenticeship rotation would be effective for teaching nontechnical skills (NTS) and core competencies., Materials and Methods: An apprenticeship rotation was created at a university-based surgery residency in which each chief resident selected a single attending surgeon with whom to work exclusively with for a 4-week period. Emphasis was placed on teaching intraoperative NTS as well as the 4 difficult-to-teach Accreditation Council for Graduate Medical Education core competencies (DCC): Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Professionalism, and Systems-Based Practice. Participants were surveyed afterwards about their rotation using a 5-point Likert scale. A Wilcoxon signed rank test was used to compare differences depending on data distribution., Results: All (13/13) the chief residents and 67% (8/12) faculty completed the survey. Overall, 85% of residents and 87.5% of faculty would recommend the rotation to other residents/faculty members. Both residents and faculty reported improvement in trainees' technical skills and NTS. Residents reported improvement in all 4 DCC, particularly, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills., Conclusion: The apprenticeship rotation is an effective means of teaching residents both NTS and DCC essential for independent practice. Consideration should be given to introducing this program into surgical curricula nationally., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Medical organizations have increased interest in identifying and improving behaviors that threaten team performance and patient safety. Three hundred and sixty degree evaluations of surgeons were performed at 8 academically affiliated hospitals with a common Code of Excellence. We evaluate participant perceptions and make recommendations for future use., Study Design: Three hundred and eighty-five surgeons in a variety of specialties underwent 360-degree evaluations, with a median of 29 reviewers each (interquartile range 23 to 36). Beginning 6 months after evaluation, surgeons, department heads, and reviewers completed follow-up surveys evaluating accuracy of feedback, willingness to participate in repeat evaluations, and behavior change., Results: Survey response rate was 31% for surgeons (118 of 385), 59% for department heads (10 of 17), and 36% for reviewers (1,042 of 2,928). Eighty-seven percent of surgeons (95% CI, 75%-94%) agreed that reviewers provided accurate feedback. Similarly, 80% of department heads believed the feedback accurately reflected performance of surgeons within their department. Sixty percent of surgeon respondents (95% CI, 49%-75%) reported making changes to their practice based on feedback received. Seventy percent of reviewers (95% CI, 69%-74%) believed the evaluation process was valuable, with 82% (95% CI, 79%-84%) willing to participate in future 360-degree reviews. Thirty-two percent of reviewers (95% CI, 29%-35%) reported perceiving behavior change in surgeons., Conclusions: Three hundred and sixty degree evaluations can provide a practical, systematic, and subjectively accurate assessment of surgeon performance without undue reviewer burden. The process was found to result in beneficial behavior change, according to surgeons and their coworkers., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: It is known that emergency surgery in the elderly is associated with high short-term mortality, but longer-term outcomes are not well described. We hypothesized that 30-day mortality may underestimate the true operative mortality experienced in this cohort. The purposes of this study were to characterize postoperative mortality rates extending to 1 year and to identify preoperative predictors of 1 year mortality after emergency abdominal surgery., Methods: We retrospectively reviewed the records of all patients older than 70 years who underwent emergency abdominal surgery at a major teaching hospital between 2006 and 2011. Demographics, preoperative physiology, prehospital status, body mass index, laboratory values, Charlson scores, comorbid conditions, American Society of Anesthesiologists classification, and operative details were recorded. The primary end point was 1-year mortality. Complementary log-log binary regression was used to determine independent predictors of death. Model discrimination was evaluated using the c statistic., Results: A total of 390 patients met our inclusion criteria. The mean age was 79 years, and 56% were women. Postoperative mortality was 16.2% at 30 days and 32.5% at 1 year, reflecting a doubling of mortality over 11 months. Independent preoperative predictors of 1-year mortality were Charlson score of 4 or higher (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.38-2.34), American Society of Anesthesiologists class of 4 or higher (HR, 1.66; 95% CI, 1.22-2.21), albumin less than 3.5 (HR, 1.71; 95% CI, 1.31-2.28), and body mass index lower than 18.5 (HR, 3.36; 95% CI, 1.48-6.86). The c statistic was 0.81., Conclusion: The 1-year mortality after emergency surgery in the elderly is significantly higher than that at 30 days. We identified a constellation of preoperative clinical markers that were highly predictive of this poor late outcome. The presence of these findings in the emergency setting should prompt preoperative discussion about treatment goals and encourage surgeons to set realistic expectations about outcomes with the patient and family. Future studies will develop a clinical scoring tool that can be applied at the bedside to provide more effective counseling for this high-risk population., Level of Evidence: Epidemiologic/prognostic study, level III; therapeutic study, level IV.

Importance: Little is known about the sustainability and long-term effect of surgical safety checklists when implemented in resource-limited settings. A previous study demonstrated the marked, short-term effect of a structured hospital-wide implementation of a surgical safety checklist in Moldova, a lower-middle-income country, as have studies in other low-resource settings., Objectives: To assess the long-term reduction in perioperative harm following the introduction of a checklist-based surgical quality improvement program in a resource-limited setting and to understand the long-term effects of such programs., Design, Setting, and Participants: Twenty months after the initial implementation of a surgical safety checklist and the provision of pulse oximetry at a referral hospital in Moldova, a lower-middle-income, resource-limited country in Eastern Europe, we conducted a prospective study of perioperative care and outcomes of 637 consecutive patients undergoing noncardiac surgery (the long-term follow-up group), and we compared the findings with those from 2106 patients who underwent surgery shortly after implementation (the short-term follow-up group). Preintervention data were collected from March to July 2010. Data collection during the short-term follow-up period was performed from October 2010 to January 2011, beginning 1 month after the implementation of the launch period. Data collection during the long-term follow-up period took place from May 25 to July 6, 2012, beginning 20 months after the initial intervention., Main Outcomes and Measures: The primary end points of interest were surgical morbidity (ie, the complication rate), adherence to safety process measures, and frequency of hypoxemia., Results: Between the short- and long-term follow-up groups, the complication rate decreased 30.7% (P = .03). Surgical site infections decreased 40.4% (P = .05). The mean (SD) rate of completion of the checklist items increased from 88% (14%) in the short-term follow-up group to 92% (11%) in the long-term follow-up group (P < .001). The rate of hypoxemic events continued to decrease (from 8.1 events per 100 hours of oximetry for the short-term follow-up group to 6.8 events per 100 hours of oximetry for the long-term follow-up group; P = .10)., Conclusions and Relevance: Sustained use of the checklist was observed with continued improvements in process measures and reductions in 30-day surgical complications almost 2 years after a structured implementation effort that demonstrated marked, short-term reductions in harm. The sustained effect occurred despite the absence of continued oversight by the research team, indicating the important role that local leadership and local champions play in the success of quality improvement initiatives, especially in resource-limited settings.

The objective of this study was to identify leading practices to promote environmentally friendly and efficient efforts in the provision of surgical health care. Health care is the second leading contributor to waste in the United States. Despite widespread enthusiasm for "going green" in the US economy, little substantive information is available to the medical community, to our knowledge. We explore safe and efficient strategies for hospitals and providers to protect the environment while delivering high-quality care. We performed a systematic review of the literature using relevant PubMed search terms and surveyed a panel of hospital managers and chief executive officers of health care organizations pursuing green initiatives. Recommendations were itemized and reviewed by a 7-member panel to generate a consensus agreement. We identified 43 published articles and used interview data from the panel. The following 5 green recommendations for surgical practices were identified: operating room waste reduction and segregation, reprocessing of single-use medical devices, environmentally preferable purchasing, energy consumption management, and pharmaceutical waste management. The medical community has a large opportunity to implement green practices in surgical units. These practices can provide significant benefits to the health care community and to the environment. Additional research and advocacy are needed to further explore green practices in health care.

Health care is one of the largest contributors to waste production in the United States. Given increased awareness of the environmental and financial costs associated with waste disposal and its public health impact, many hospitals are adopting environmentally friendly practices that reduce waste production and offer equally effective, yet less expensive alternatives. Reprocessing of medical equipment is one such practice that has gained popularity in recent years and has led to major cost savings across several medical disciplines. In this commentary, we seek to take a closer look at the practice of reprocessing, explore the evidence surrounding its safety, and suggest implications of reprocessing for medical centers.

Neuropeptide Y is the ligand of a family of G-protein coupled receptors (Y(1) to Y(6)). In the thalamus, exogenous and endogenously released NPY can shorten the duration of thalamic oscillations in brain slices from P13 to P15 rats, an in vitro model of absence seizures. Here, we examine which Y receptors are involved in this modulation. Application of the Y(1) receptor agonist Leu(31)Pro(34)NPY caused a reversible reduction in the duration of thalamic oscillations (-26.6+/-7.8%), while the Y(2) receptor agonist peptideYY((3-36)) and the Y(5) receptor agonist BWX-46 did not exert a significant effect. No Y receptor agonist affected oscillation period. Application of antagonists of Y(1), Y(2) and Y(5) receptors (BIBP3226, BIIE0246 and L152,806, respectively) produced results consistent with those obtained from agonists. BIBP3226 caused a reversible disinhibition, an effect that increases oscillation duration (18.2+/-9.7%) while BIIE0246 and L152,806 had no significant effect. Expression of NPY is limited to neurons in the reticular thalamic nucleus (nRt), but Y(1) receptors are expressed in both nRt and adjacent thalamic relay nuclei. Thus, intra-nRt or nRt to relay nucleus NPY release could cause Y(1) receptor mediated inhibition of thalamic oscillations.