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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.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).Program implementation took place at the University of Michigan in Ann Arbor, MI.Medical students, general surgery residents, and general surgery faculty were recruited.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.

A substantial knowledge gap exists in understanding sex as a biological variable for abdominal wall hernia repair, which also extends to hernia repair practices in females of childbearing age. We sought to determine the incidence of mesh repairs in females of childbearing age and to characterize factors associated with mesh use.Using a statewide hernia-specific data registry, we conducted a retrospective study identifying females of childbearing age, defined as 18-44 per CDC guidelines, who underwent clean ventral hernia repair between January 2020 and Dec 2021. The primary outcome was mesh use. Multivariable logistic regression was used to examine factors associated with mesh use. To further delineate whether childbearing status may affect decision to use mesh, we also examined mesh practice stratified by age, comparing women 18 to 44 to those 45 and older.Eight hundred and thirty-six females of childbearing age underwent ventral hernia repair with a mean age of 34.8 (6.2) years. Mesh was used in 547 (65.4%) patients. Mesh use was significantly associated with minimally invasive approach [aOR 29.46 (95% CI 16.30-53.25)], greater hernia width [aOR 1.50 (95% CI 1.20-1.88)], and greater BMI [aOR 1.05 (95% CI 1.03-1.08)]. Age was not significantly associated with mesh use [aOR 1.02 (95% CI 0.99-1.05)]. Compared to 1,461 female patients older than 44 years old, there was no significant association between childbearing age and mesh use [aOR 0.77 (95% CI 0.57-1.04)].Most females of childbearing age had mesh placed during ventral and incisional hernia repair, which was largely associated with hernia size, BMI, and a minimally invasive surgical approach. Neither chronologic patient age nor being of childbearing age were associated with mesh use. Insofar as existing evidence suggests that childbearing status is an important factor in deciding whether to use mesh, these findings suggest that real-world practice may not reflect that evidence.

Although bariatric surgery is the most effective treatment for obesity and weight-related comorbid diseases, utilization rates are disproportionately low among non-white patients. We sought to understand if variation in baseline characteristics or access to care exists between white and non-white patients.Using a statewide bariatric-specific data registry, we evaluated all patients who underwent bariatric surgery between 2006 and 2020 and completed a preoperative baseline questionnaire, which included a question about self-identification of race. Patient characteristics, co-morbidities, and time from initial preoperative clinic evaluation to date of surgery were compared among racial groups.A total of 73,141 patients met inclusion criteria with 18,741 (25.5%) self-identified as non-white. These included Black/African American (n = 11,904), Hispanic (n = 3448), Asian (n = 121), Native Hawaiian/Pacific Islander (n = 41), Middle Eastern (n = 164), Multiple (n = 2047) and other (n = 608). Non-white males were the least represented group, accounting for only 4% of all bariatric cases performed. Non-white patients were more likely to be younger (43.0 years vs. 46.6 years, p 0.0001), disabled (16% vs. 11.4%, p 0.0001) and have Medicaid (8.4% vs. 3.8%, p 0.0001) when compared to white patients, despite having higher rates of college education (78.0% vs. 76.6, p 0.0001). In addition, median time from initial evaluation to surgery was also longer among non-white patients (157 days vs. 127 days, p 0.0001), despite having higher rates of patients with a body mass index above 50 kg/mNon-white patients undergoing bariatric surgery represent an extremely diverse group of patients with more socioeconomic disadvantages and longer wait times when compared to white patients despite presenting with higher rates of severe obesity. Current guidelines and referral patterns for bariatric surgery may not be equitable and need further examination when considering the management of obesity within diverse populations to reduce disparities in care-of which non-white males are particularly at risk.

Research has shown that barriers to career success in academic medicine disproportionately affect women. These barriers include inadequate mentoring, which may perpetuate the underrepresentation of women in senior leadership positions. The purpose of this review was to summarize the qualitative and quantitative evidence of the impact of mentoring on women's career outcomes and to inform future interventions to support the promotion and retention of women in academic medicine.The authors conducted a systematic review of original research published in English-language, peer-reviewed journals through March 20, 2020. Search terms related to mentorship, women, and academic medicine. The authors searched MEDLINE, Embase, Scopus, Current Contents Connect via Web of Science, Cochrane Library, and PsycINFO. They excluded studies not specifically addressing women and those without gender-stratified outcomes. They extracted and analyzed the following data: study design, population, sample size, response rate, participant age, percentage of women, mentoring prevalence, and outcomes.Of 2,439 citations identified, 91 studies met the inclusion criteria, including 65 quantitative and 26 qualitative studies. Mentoring was associated with objective and subjective measures of career success. Women perceived mentorship to be more valuable to their career development yet were more likely to report having no mentor. Additionally, women were more likely to report lower levels of research productivity, less career satisfaction, and greater barriers to promotion. Qualitative results indicated that women had less access to informal mentoring and family responsibilities had a greater effect on their career outcomes. Professional networking, female mentors, and relational aspects of mentoring were common themes.This review examined gender disparities in mentoring and the impact on research productivity, promotion success, and career satisfaction for women in academic medicine. Institution-supported mentoring programs are needed to facilitate identification of appropriate mentors and promotion of a more equitable academic career environment for women.

Supplementary Figures 1-4, Table 1 from Multiple Roles for the Receptor Tyrosine Kinase Axl in Tumor Formation

Supplementary Figure and Table Legends from Multiple Roles for the Receptor Tyrosine Kinase Axl in Tumor Formation

This case highlights a 37-year-old woman with primary sclerosing cholangitis awaiting liver transplantation who presented with torsion of a wandering spleen with associated gastric and pancreatic volvulus. The patient underwent emergent exploratory laparotomy with splenectomy. She had an uncomplicated postoperative course and recovered well.

This cohort study uses data from the Health and Retirement Study and Medicare claims to examine the association between loneliness and postoperative mortality after elective vs nonelective surgery among older adults.

Introduction Patients with psychiatric or substance use disorders (SUD) and those experiencing homelessness have been identified as populations likely disproportionately affected by frostbite injury. However, the literature is sparse in regards to morbidity and mortality in these patients. As such, we sought to examine and characterize factors associated with worse outcomes and increased resource utilization in this patient population. Methods Adult patients admitted to a single ABA-accredited burn center for frostbite between 2013-2021 were identified using an institution-specific data registry. A retrospective chart review was conducted on patients meeting inclusion criteria, as identified by ICD-10 and ICD-9 codes. The primary outcome was morbidity and mortality associated with frostbite, including hospital length of stay, number of operations, and readmission. Chi-square and t-tests were utilized to compare patients with and without SUD (alcohol, drug, or positive urine drug screen), psychiatric disorders, or homelessness. Results In total, 54 patients were identified (70% male), 19% had documented non-alcoholic SUD, 50% had alcohol use disorder, and 14% were homeless. No significant differences were found between these patients and others in terms of the number of operations or amputations required. However, patients with positive SUD screen (32.0% vs 8.0% p=0.03), positive UDS (46.7% vs. 0%, p=0.015), psychiatric disorders (27% vs. 0%, p=0.034), active drug use (50% vs 14.3%, p=0.01), or homelessness (50% vs 15%, p=0.026) were more likely to be readmitted with wound infections or progression of gangrene. Finally, patients with psychiatric disorders were more likely to require additional operations (1.8 vs 0.6, p=0.02) and longer length of hospital stay (16.0 +/- 2.9 vs 7.7 +/- 2.8, p=0.046). Conclusions Our results suggest significant differences in resource utilization and morbidity between those with and without a history of SUD, psychiatric disorder, or homelessness. Subsequent allocation of resources should target outpatient needs of at-risk patients to avoid similar outcomes. Future research should be focused on elucidating reasons for these differences which may include issues accessing follow-up care, inability to adhere to wound care, and more.

Bowel obstructions can have a variety of causes, including impacted feces, adhesions, volvulus, non-internal hernias, and in rare cases internal hernias. We report a 63-year-old woman who presented to the emergency department with severe abdominal pain, nausea, vomiting, and obstructive symptoms that had started 12 hours earlier. A computed tomographic scan of the abdomen and pelvis showed a right internal hernia with a cecal bascule traversing through the foramen of Winslow, concerning for a closed-loop obstruction. The patient underwent an exploratory laparotomy with cecal bascule reduction and cecopexy. Given the increased mortality risk if undiagnosed, it is important to remain aware of internal hernias. Patient outcomes are markedly improved with early diagnosis and surgical intervention.

Background The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated equivalent survival in early-stage breast cancer (BC) patients receiving either axillary lymph node dissection (ALND) or sentinel lymph node dissection (SLND) alone. However, institutional studies have called into question the generalization of these findings outside of a clinical trial. Methods Early-stage BC patients diagnosed in 2013, that received lumpectomy with whole-breast irradiation, and underwent either ALND or SLND alone, in National Cancer Database were included. Weighted Kaplan-Meier curves were used to estimate 45-month survival, accounting for demographics, comorbidities, insurance type, cancer and neighborhood characteristics. Results 62,184 patients were included, of which 21,892 (35%) underwent ALND. Patients undergoing ALND, compared to SLND, appeared to have slightly lower survival (91.4% vs 95.1%); moreover, even after weighting, a small difference persisted (92.7% vs 94.7%, RR 0.98, 95% CI 0.97, 0.99). Conclusions SLND is a safe and effective alternative to ALND in BC patients with limited nodal involvement. This study provides additional evidence that the findings of ACOSOG Z0011 are applicable to the larger early-stage BC population.

BACKGROUND Serum albumin level is the most well-established serum marker of malnutrition, with a serum albumin concentration

Several studies have suggested that malnutrition may be associated with periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). However, strong evidence for this association is lacking. The purpose of the present study is to ask, Is the proportion of patients with hypoalbuminemia (a proxy for malnutrition) higher among patients with a septic indication for revision TJA than patients with an aseptic indication for revision TJA? Secondly, among patients undergoing revision TJA for an aseptic indication, is hypoalbuminemia predictive of subsequent early postoperative PJI?Patients undergoing revision total hip or knee arthroplasty were identified in the American College of Surgeons National Surgical Quality Improvement Program. Hypoalbuminemia was defined as serum albumin3.5 g/dL. All analyses were adjusted for differences in demographic, comorbidity, and procedural characteristics.A total of 4517 patients met inclusion criteria, of which 715 (15.8%) underwent revision for a septic indication. Patients undergoing revision for a septic indication had a higher rate of hypoalbuminemia than patients undergoing revision for an aseptic indication (42.8% vs 11.8%; relative risk = 3.6, 95% confidence interval = 3.2-4.1, P.001). Of the 3802 patients who underwent revision TJA for an aseptic indication, patients with hypoalbuminemia had a higher rate of early PJI after the revision than patients with normal serum albumin levels (4.5% vs 2.1%; relative risk = 2.1, 95% CI = 1.2-3.5, P = .005).These findings add to the growing body of evidence that malnutrition increases the risk of PJI after TJA. Future prospective studies should consider whether correcting malnutrition preoperatively reduces the risk of PJI after TJA.

A retrospective review of data collected prospectively by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).The aim of this study was to investigate the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days following posterior lumbar fusion surgery.Malnutrition is a potentially modifiable risk factor that may contribute to complications following spinal surgery. Although prior studies have identified associations between malnutrition, delayed wound healing, and surgical site infection (SSI), the evidence for such a relationship within spine surgery is mixed.Patients who underwent posterior lumbar spinal fusion of one to three levels as part of the ACS-NSQIP were identified. Patients without preoperative serum albumin concentration were excluded. Outcomes were compared between patients with and without hypoalbuminemia (defined as serum albumin concentration3.5 g/dL). All comparisons were adjusted for baseline differences between populations.Four thousand three hundred ten patients were included. The prevalence of hypoalbuminemia was 4.8%. In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for occurrence of wound dehiscence [1.5% vs. 0.2%, adjusted relative risk (RR) = 5.8, P = 0.006], SSI (5.4% vs. 1.7%, adjusted RR = 2.3, P = 0.010), and urinary tract infection (5.4% vs. 1.5%, adjusted RR = 2.5, P = 0.005). Similarly, patients with hypoalbuminemia had a higher risk for unplanned hospital readmission within 30 days of surgery (11.7% vs. 5.4%, RR = 1.8, P 0.001). Finally, patients with hypoalbuminemia had a longer mean inpatient stay (5.2 vs. 3.7 days, RR = 1.2, P 0.001).The present study suggests that malnutrition is an independent risk factor for infectious and wound complications following posterior lumbar fusion. Malnutrition was also associated with an increased length of stay and readmission. Future studies should evaluate methods of correcting malnutrition before lumbar spinal surgery. Such efforts have the potential to meaningfully decrease the rates of adverse events following this procedure.3.

This study investigates the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days after total joint arthroplasty. Patients who underwent elective primary total hip and knee arthroplasty as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration

A focus of contemporary cancer therapeutic development is the targeting of both the transformed cell and the supporting cellular microenvironment. Cell migration is a fundamental cellular behavior required for the complex interplay between multiple cell types necessary for tumor development. We therefore developed a novel retroviral-based screening technology in primary human endothelial cells to discover genes that control cell migration. We identified the receptor tyrosine kinase Axl as a novel regulator of endothelial cell haptotactic migration towards the matrix factor vitronectin. Using small interfering RNA–mediated silencing and overexpression of wild-type or mutated receptor proteins, we show that Axl is a key regulator of multiple angiogenic behaviors including endothelial cell migration, proliferation, and tube formation in vitro. Moreover, using sustained, retrovirally delivered short hairpin RNA (shRNA) Axl knockdown, we show that Axl is necessary for in vivo angiogenesis in a mouse model. Furthermore, we show that Axl is also required for human breast carcinoma cells to form a tumor in vivo. These findings indicate that Axl regulates processes vital for both neovascularization and tumorigenesis. Disruption of Axl signaling using a small-molecule inhibitor will hence simultaneously affect both the tumor and stromal cell compartments and thus represents a unique approach for cancer therapeutic development.