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An Emerging Racial Disparity in US Motor Vehicle Fatalities. 美国机动车死亡事故中新出现的种族差异。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2247
Maxim Massenkoff, Aaron Chalfin, Aartik Sarma
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引用次数: 0
Primary Care Use and 90-Day Mortality Among Older Adults Undergoing Cancer Surgery. 接受癌症手术的老年人使用初级保健和 90 天死亡率。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2598
Hadiza S Kazaure, N Ben Neely, Lauren E Howard, Terry Hyslop, Mohammad Shahsahebi, Leah L Zullig, Kevin C Oeffinger

Importance: Multimorbidity and postoperative clinical decompensation are common among older surgical patients with cancer, highlighting the importance of primary care to optimize survival. Little is known about the association between primary care use and survivorship among older adults (aged ≥65 years) undergoing cancer surgery.

Objective: To examine primary care use among older surgical patients with cancer and its association with mortality.

Design, setting, and participants: In this retrospective cohort study, data were abstracted from the electronic health record of a single health care system for older adults undergoing cancer surgery between January 1, 2017, and December 31, 2019. There were 3 tiers of stratification: (1) patients who had a primary care practitioner (PCP) (physician, nurse practitioner, or physician assistant) vs no PCP, (2) those who had a PCP and underwent surgery in the same health system (unfragmented care) vs not (fragmented care), and (3) those who had a primary care visit within 90 postoperative days vs not. Data were analyzed between August 2023 and January 2024.

Exposure: Primary care use after surgery for colorectal, head and neck, prostate, ovarian, pancreatic, breast, liver, renal cell, non-small cell lung, endometrial, gastric, or esophageal cancer.

Main outcomes and measures: Postoperative 90-day mortality was analyzed using inverse propensity weighted Kaplan-Meier curves, with log-rank tests adjusted for propensity scores.

Results: The study included 2566 older adults (mean [SEM] age, 72.9 [0.1] years; 1321 men [51.5%]). Although 2404 patients (93.7%) had health insurance coverage, 743 (28.9%) had no PCP at the time of surgery. Compared with the PCP group, the no-PCP group had a higher 90-day postoperative mortality rate (2.0% vs 3.6%, respectively; adjusted P = .03). For the 823 patients with unfragmented care, 400 (48.6%) had a primary care visit within 90 postoperative days (median time to visit, 34 days; IQR, 20-57 days). Patients who had a postoperative primary care visit were more likely to be older, have a higher comorbidity burden, have an emergency department visit, and be readmitted. However, they had a significantly lower 90-day postoperative mortality rate than those who did not have a primary care visit (0.3% vs 3.3%, respectively; adjusted P = .001).

Conclusions and relevance: These findings suggest that follow-up with primary care within 90 days after cancer surgery is associated with improved survivorship among older adults.

重要性:在老年癌症手术患者中,多病症和术后临床失代偿现象很常见,这凸显了初级保健对优化生存的重要性。人们对接受癌症手术的老年人(年龄≥65 岁)使用初级医疗服务与存活率之间的关系知之甚少:研究老年癌症手术患者使用初级医疗服务的情况及其与死亡率的关系:在这项回顾性队列研究中,从单一医疗保健系统的电子健康记录中抽取了2017年1月1日至2019年12月31日期间接受癌症手术的老年人的数据。共分为三层:(1)有初级保健医生(PCP)(医生、护士或医生助理)的患者与没有初级保健医生的患者;(2)有初级保健医生且在同一医疗系统接受手术的患者(非碎片化护理)与没有初级保健医生的患者(碎片化护理);(3)术后 90 天内接受初级保健访问的患者与没有初级保健访问的患者。数据分析时间为 2023 年 8 月至 2024 年 1 月:暴露:结直肠癌、头颈部癌、前列腺癌、卵巢癌、胰腺癌、乳腺癌、肝癌、肾细胞癌、非小细胞肺癌、子宫内膜癌、胃癌或食管癌术后的初级护理:采用反倾向加权卡普兰-梅耶曲线分析术后90天死亡率,并根据倾向得分进行对数秩检验:研究纳入了 2566 名老年人(平均 [SEM] 年龄 72.9 [0.1]岁;1321 名男性 [51.5%])。虽然有 2404 名患者(93.7%)享有医疗保险,但其中 743 名患者(28.9%)在手术时没有初级保健医生。与初级保健医生组相比,无初级保健医生组的术后 90 天死亡率更高(分别为 2.0% 和 3.6%;调整后 P = 0.03)。在 823 名接受非碎片化护理的患者中,有 400 人(48.6%)在术后 90 天内接受了初级保健就诊(就诊时间中位数为 34 天;IQR 为 20-57 天)。术后接受初级保健就诊的患者更有可能年龄较大、合并症较多、曾在急诊科就诊并再次入院。然而,他们的术后 90 天死亡率却明显低于没有接受初级保健就诊的患者(分别为 0.3% vs 3.3%;调整后 P = .001):这些研究结果表明,在癌症手术后 90 天内进行初级保健随访与改善老年人的存活率有关。
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引用次数: 0
Expanding the Surgical Armamentarium Through Meaningful Use of the Electronic Health Record. 通过有意义地使用电子病历扩大外科手术范围。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2240
Jeniann Yi, Chen-Tan Lin, Sarah Tevis
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引用次数: 0
Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury. 脊髓损伤后撤除生命支持和死亡率中与保险有关的差异。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2967
Husain Shakil, Ahmad Essa, Armaan K Malhotra, Rachael H Jaffe, Christopher W Smith, Eva Y Yuan, Yingshi He, Jetan H Badhiwala, François Mathieu, Michael C Sklar, Duminda N Wijeysundera, Karim Ladha, Avery B Nathens, Jefferson R Wilson, Christopher D Witiw

Importance: Identifying disparities in health outcomes related to modifiable patient factors can improve patient care.

Objective: To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance.

Design, setting, and participants: This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024.

Exposure: Uninsured or public insurance compared with private insurance.

Main outcomes and measures: Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients.

Results: The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses.

Conclusions and relevance: Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

重要性:确定与可改变的患者因素相关的健康结果差异可以改善患者护理:比较不同保险类型的完全性颈椎脊髓损伤(SCI)患者退出生命支持治疗(WLST)的可能性和死亡率:这项回顾性队列研究收集了 2013 年至 2020 年期间参与 "创伤质量改进计划 "的 498 家创伤中心的数据。参与者包括完全性颈椎 SCI 的成年患者(16 岁以上)。数据分析时间为 2023 年 11 月 1 日至 2024 年 5 月 18 日。风险暴露:无保险或公共保险与私人保险的比较:主要结果和测量指标:主要结果为WLST和死亡率。采用分层逻辑回归法估算每个结果的调整后几率比(aOR)。倾向评分匹配作为一种替代分析方法,用于比较公共保险和私人保险患者。比较了匹配患者的护理过程结果,包括住院并发症发生率和住院时间:研究纳入了在 498 家创伤中心接受治疗的 8421 名完全性颈椎 SCI 患者(平均 [SD] 年龄为 49.1 [20.2] 岁;6742 名男性 [80.1%])。在 3524 名购买了私人保险的患者中,503 人接受了 WLST(14.3%),756 人死亡(21.5%)。在 3957 名购买了公共保险的患者中,906 人(22.2%)患有 WLST,1209 人(30.6%)死亡。在 940 名未参保的患者中,156 人(16.6%)接受了 WLST,318 人(33.8%)死亡。在调整后的 WLST 发生几率(aOR,1.49;95% CI,1.11-2.01)和死亡率(aOR,1.98;95% CI,1.50-2.60)方面,未参保患者和私人参保患者之间存在明显差异。在分组分析中也发现了类似的结果。与私人保险患者相比,匹配的公共保险患者出现住院并发症的几率明显更高(几率比1.27;95% CI,1.14-1.42),住院时间更长(平均差异5.90天;95% CI,4.64-7.20),这一点在亚组分析中再次得到证实:在本研究中,医疗保险类型与完全性颈椎 SCI 患者发生 WLST 的几率、死亡率、住院并发症和住院天数的显著差异有关。今后的工作需要纳入患者的观点,并确定策略以缩小大量无私人保险患者的质量差距。
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引用次数: 0
Cracks in the Glass Ceiling-Except for Pregnant Surgery Residents. 玻璃天花板上的裂缝--怀孕的外科住院医师除外。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2404
Jamie E Anderson, Diana L Farmer
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引用次数: 0
Providing a Safe Pregnancy Experience for Surgeons: A Review. 为外科医生提供安全的孕期体验:回顾。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.0979
Tiffany A Glazer, Kirsten A Gunderson, Elise Deroo, Ellen C Shaffrey, Hayley Mann, Maya N Matabele, Rebecca M Minter, J Igor Iruretagoyena, John E Rectenwald

Importance: Childbearing has been a particular barrier to successful recruitment and retention of women in surgery. Pregnant surgeons are more likely to have major pregnancy complications, such as preterm delivery, intrauterine growth restriction, infertility, and miscarriage, compared with nonsurgeons. The average obstetric complication rate for surgeons ranges between 25% and 82% in the literature and is considerably higher than that in the general US population at 5% to 15%.

Observations: The risks that pregnant surgeons experience were individually analyzed. These risks included missed prenatal care; musculoskeletal hazards, such as prolonged standing, lifting, and bending; long work hours; overnight calls; exposure to teratogenic agents, such as ionizing radiation, anesthetic gases, chemotherapy agents, and methyl methacrylate; and psychological stress and discrimination from the long-standing stigma associated with balancing motherhood and professional life.

Conclusions and relevance: A clear, translatable, and enforceable policy addressing perinatal care of surgeons was proposed, citing evidence of the risks reviewed from the literature. A framework of protection for pregnant individuals is essential for attracting talented students into surgery, retaining talented surgical trainees and faculty, and protecting pregnant surgeons and their fetuses.

重要性:生育一直是外科成功招聘和留住女性的一个特殊障碍。与非外科医生相比,怀孕的外科医生更容易出现重大妊娠并发症,如早产、宫内发育受限、不孕和流产。在文献中,外科医生的平均产科并发症发生率在 25% 到 82% 之间,大大高于美国普通人群的 5% 到 15% 的发生率:对怀孕外科医生经历的风险进行了单独分析。这些风险包括错过产前护理;肌肉骨骼危害,如长时间站立、举起和弯腰;工作时间长;通宵值班;接触致畸物质,如电离辐射、麻醉气体、化疗药物和甲基丙烯酸甲酯;以及因长期以来在母亲身份和职业生活之间取得平衡而遭受的耻辱所带来的心理压力和歧视:引用文献中的风险证据,提出了一项针对外科医生围产期护理的明确、可转化和可执行的政策。一个保护孕妇的框架对于吸引优秀学生进入外科、留住优秀外科学员和教师以及保护怀孕外科医生及其胎儿至关重要。
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引用次数: 0
Postlumpectomy Mammography for Management of Breast Cancers With Microcalcifications. 乳腺癌微钙化切除术后的乳腺造影管理。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2054
Josh Johnson, Georgia Syrnioti, Claire M Eden, Genevieve Fasano, Anni Liu, Xi Kathy Zhou, Lisa A Newman
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引用次数: 0
Strategies to Mitigate Food Insecurity in Patients Undergoing Surgery. 缓解手术患者食物不安全的策略。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2570
Anam N Ehsan, Seth A Berkowitz, Kavitha Ranganathan
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引用次数: 0
Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients. 高风险儿科创伤患者的静脉血栓栓塞预防。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2487
Amanda B Witte, Kyle Van Arendonk, Carisa Bergner, Martin Bantchev, Richard A Falcone, Suzanne Moody, Heather A Hartman, Emily Evans, Rajan Thakkar, Kelli N Patterson, Peter C Minneci, Grace Z Mak, Mark B Slidell, MacKenton Johnson, Matthew P Landman, Troy A Markel, Charles M Leys, Linda Cherney Stafford, Jessica Draper, David S Foley, Cynthia Downard, Tracy M Skaggs, Dave R Lal, David Gourlay, Peter F Ehrlich

Importance: The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively.

Objective: To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.

Design, setting, and participants: This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE.

Exposures: Receipt and timing of chemical VTE prophylaxis.

Main outcomes and measures: The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation.

Results: Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE.

Conclusions and relevance: In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

重要性:儿科创伤患者预防化学性静脉血栓栓塞症(cVTE)的适应症、安全性和有效性仍不明确。最近推荐使用一套高风险标准来指导 cVTE 的使用,但尚未对这些标准进行前瞻性评估:在一项针对儿科创伤患者的多机构前瞻性研究中,研究高风险标准和 cVTE 的使用:这项队列研究于 2019 年 10 月至 2022 年 10 月期间在 8 家被指定为美国外科学院一级儿科创伤中心的独立儿科医院完成。参与者均为入院时符合规定高风险标准的 18 岁以下儿科创伤患者。假设 cVTE 是安全的,并能降低 VTE 的发生率:主要结果和测量指标:主要结果和测量指标:主要结果是按接受 cVTE 和时间分层的 VTE 总发生率。次要结果是根据抗凝治疗引起的出血或其他并发症来衡量 cVTE 的安全性:在 460 名高风险儿科创伤患者中,中位(IQR)年龄为 14.5 岁(10.4-16.2 岁);313 名患者(68%)为男性,147 名患者(32%)为女性。受伤严重程度评分(ISS)的中位数(IQR)为 23(16-30),高危因素的中位数(IQR)为 3(2-4)。共有 251 名(54.5%)患者接受了 cVTE;62 名(13.5%)患者在入院 24 小时内接受了 cVTE。24 小时后接受 cVTE 的患者具有更多的高危因素和更高的 ISS。延迟发生 cVTE 的最常见原因是中枢神经系统出血(120 例患者;30.2%)。25 名患者中发生了 28 起 VTE 事件(5.4%)。62 名患者中有 1 人(1.6%)在 24 小时内接受了 cVTE,189 名患者中有 13 人(6.9%)在 24 小时后接受了 cVTE,209 名患者中有 11 人(5.3%)没有发生 cVTE(P = .31)。从入院到开始接受 cVTE 的时间越长,VTE 的发生率越高(几率比 1.01;95% CI,1.00-1.01;P = .01)。在患者接受 cVTE 治疗期间,未观察到出血并发症:在这项前瞻性研究中,根据一套高风险标准使用 cVTE 是安全的,不会导致出血并发症。延迟开始使用 cVTE 与 VTE 的发生密切相关。提高儿科 VTE 预防质量的关键在于预防时机和实施障碍。
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引用次数: 0
Pregnancy and Parenthood Among US Surgical Residents. 美国外科住院医生的怀孕和生育情况。
IF 15.7 1区 医学 Q1 SURGERY Pub Date : 2024-10-01 DOI: 10.1001/jamasurg.2024.2399
Ruojia Debbie Li, Lauren M Janczewski, Joshua S Eng, Darci C Foote, Christine Wu, Julie K Johnson, Sarah Rae Easter, Eugene Kim, Jo Buyske, Patricia L Turner, Thomas J Nasca, Karl Y Bilimoria, Yue-Yung Hu, Erika L Rangel
<p><strong>Importance: </strong>The ability to pursue family planning goals is integral to gender equity in any field. Procedural specialties pose occupational risks to pregnancy. As the largest procedural specialty, general surgery provides an opportunity to understand family planning, workplace support for parenthood, obstetric outcomes, and the impact of these factors on workforce well-being, gender equity, and attrition.</p><p><strong>Objective: </strong>To examine pregnancy and parenthood experiences, including mistreatment and obstetric outcomes, among a cohort of US general surgical residents.</p><p><strong>Design, setting, and participants: </strong>This cohort study involved a cross-sectional national survey of general surgery residents in all programs accredited by the Accreditation Council for Graduate Medical Education after the 2021 American Board of Surgery In-Training Examination. Female respondents who reported a pregnancy and male respondents whose partners were pregnant during clinical training were queried about pregnancy- and parenthood-based mistreatment, obstetric outcomes, and current well-being (burnout, thoughts of attrition, suicidality).</p><p><strong>Main outcomes and measures: </strong>Primary outcomes included obstetric complications and postpartum depression compared between female residents and partners of male residents. Secondary outcomes included perceptions about support for family planning, pregnancy, or parenthood; assisted reproductive technology use; pregnancy/parenthood-based mistreatment; neonatal complications; and well-being, compared between female and male residents.</p><p><strong>Results: </strong>A total of 5692 residents from 325 US general surgery programs participated (81.2% response rate). Among them, 957 residents (16.8%) reported a pregnancy during clinical training (692/3097 [22.3%] male vs 265/2595 [10.2%] female; P < .001). Compared with male residents, female residents more frequently delayed having children because of training (1201/2568 [46.8%] females vs 1006/3072 [32.7%] males; P < .001) and experienced pregnancy/parenthood-based mistreatment (132 [58.1%] females vs 179 [30.5%] males; P < .001). Compared with partners of male residents, female residents were more likely to experience obstetric complications (odds ratio [OR], 1.42; 95% CI, 1.04-1.96) and postpartum depression (OR, 1.63; 95% CI, 1.11-2.40). Pregnancy/parenthood-based mistreatment was associated with increased burnout (OR, 2.03; 95% CI, 1.48-2.78) and thoughts of attrition (OR, 2.50; 95% CI, 1.61-3.88). Postpartum depression, whether in female residents or partners of male residents, was associated with resident burnout (OR, 1.93; 95% CI, 1.27-2.92), thoughts of attrition (OR, 2.32; 95% CI, 1.36-3.96), and suicidality (OR, 5.58; 95% CI, 2.59-11.99).</p><p><strong>Conclusions and relevance: </strong>This study found that pregnancy/parenthood-based mistreatment, obstetric complications, and postpartum depression were associ
重要性:在任何领域,追求计划生育目标的能力都是性别平等不可或缺的一部分。手术专业存在怀孕的职业风险。作为最大的手术专科,普通外科提供了一个了解计划生育、工作场所对为人父母的支持、产科结果以及这些因素对劳动力福利、性别平等和自然减员的影响的机会:研究美国普通外科住院医师群体的怀孕和育儿经历,包括虐待和产科结果:这项队列研究是一项横断面全国性调查,调查对象是在 2021 年美国外科学委员会在职培训考试后获得美国毕业医学教育认证委员会认证的所有项目中的普外科住院医师。调查询问了在临床培训期间报告怀孕的女性受访者和其伴侣怀孕的男性受访者有关基于怀孕和养育子女的虐待、产科结果和当前幸福感(职业倦怠、减员想法、自杀倾向)的情况:主要结果包括女性住院医师与男性住院医师伴侣的产科并发症和产后抑郁症比较。次要结果包括对计划生育、怀孕或为人父母支持的看法;辅助生殖技术的使用;基于怀孕/为人父母的虐待;新生儿并发症;以及女性和男性住院医师的幸福感:共有来自 325 个美国普外科项目的 5692 名住院医师参与(回复率为 81.2%)。其中,957 名住院医师(16.8%)报告在临床培训期间怀孕(692/3097 [22.3%] 男性 vs 265/2595 [10.2%] 女性;P 结论及相关性:本研究发现,基于妊娠/父母身份的虐待、产科并发症和产后抑郁与女性性别有关,这可能是导致性别减员的原因。需要进行系统性变革,以保护母胎健康并促进程序领域的性别平等。
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引用次数: 0
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