Pub Date : 2024-10-01DOI: 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.
{"title":"Primary Care Use and 90-Day Mortality Among Older Adults Undergoing Cancer Surgery.","authors":"Hadiza S Kazaure, N Ben Neely, Lauren E Howard, Terry Hyslop, Mohammad Shahsahebi, Leah L Zullig, Kevin C Oeffinger","doi":"10.1001/jamasurg.2024.2598","DOIUrl":"10.1001/jamasurg.2024.2598","url":null,"abstract":"<p><strong>Importance: </strong>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.</p><p><strong>Objective: </strong>To examine primary care use among older surgical patients with cancer and its association with mortality.</p><p><strong>Design, setting, and participants: </strong>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.</p><p><strong>Exposure: </strong>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.</p><p><strong>Main outcomes and measures: </strong>Postoperative 90-day mortality was analyzed using inverse propensity weighted Kaplan-Meier curves, with log-rank tests adjusted for propensity scores.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions and relevance: </strong>These findings suggest that follow-up with primary care within 90 days after cancer surgery is associated with improved survivorship among older adults.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11307163/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141897383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1001/jamasurg.2024.2240
Jeniann Yi, Chen-Tan Lin, Sarah Tevis
{"title":"Expanding the Surgical Armamentarium Through Meaningful Use of the Electronic Health Record.","authors":"Jeniann Yi, Chen-Tan Lin, Sarah Tevis","doi":"10.1001/jamasurg.2024.2240","DOIUrl":"10.1001/jamasurg.2024.2240","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 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.
{"title":"Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury.","authors":"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","doi":"10.1001/jamasurg.2024.2967","DOIUrl":"10.1001/jamasurg.2024.2967","url":null,"abstract":"<p><strong>Importance: </strong>Identifying disparities in health outcomes related to modifiable patient factors can improve patient care.</p><p><strong>Objective: </strong>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.</p><p><strong>Design, setting, and participants: </strong>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.</p><p><strong>Exposure: </strong>Uninsured or public insurance compared with private insurance.</p><p><strong>Main outcomes and measures: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusions and relevance: </strong>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.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11325240/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975718","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1001/jamasurg.2024.2404
Jamie E Anderson, Diana L Farmer
{"title":"Cracks in the Glass Ceiling-Except for Pregnant Surgery Residents.","authors":"Jamie E Anderson, Diana L Farmer","doi":"10.1001/jamasurg.2024.2404","DOIUrl":"10.1001/jamasurg.2024.2404","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 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.
{"title":"Providing a Safe Pregnancy Experience for Surgeons: A Review.","authors":"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","doi":"10.1001/jamasurg.2024.0979","DOIUrl":"10.1001/jamasurg.2024.0979","url":null,"abstract":"<p><strong>Importance: </strong>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%.</p><p><strong>Observations: </strong>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.</p><p><strong>Conclusions and relevance: </strong>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.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975721","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1001/jamasurg.2024.2054
Josh Johnson, Georgia Syrnioti, Claire M Eden, Genevieve Fasano, Anni Liu, Xi Kathy Zhou, Lisa A Newman
{"title":"Postlumpectomy Mammography for Management of Breast Cancers With Microcalcifications.","authors":"Josh Johnson, Georgia Syrnioti, Claire M Eden, Genevieve Fasano, Anni Liu, Xi Kathy Zhou, Lisa A Newman","doi":"10.1001/jamasurg.2024.2054","DOIUrl":"10.1001/jamasurg.2024.2054","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11292560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141855526","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1001/jamasurg.2024.2570
Anam N Ehsan, Seth A Berkowitz, Kavitha Ranganathan
{"title":"Strategies to Mitigate Food Insecurity in Patients Undergoing Surgery.","authors":"Anam N Ehsan, Seth A Berkowitz, Kavitha Ranganathan","doi":"10.1001/jamasurg.2024.2570","DOIUrl":"10.1001/jamasurg.2024.2570","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142017423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 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.
{"title":"Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients.","authors":"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","doi":"10.1001/jamasurg.2024.2487","DOIUrl":"10.1001/jamasurg.2024.2487","url":null,"abstract":"<p><strong>Importance: </strong>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.</p><p><strong>Objective: </strong>To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.</p><p><strong>Design, setting, and participants: </strong>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.</p><p><strong>Exposures: </strong>Receipt and timing of chemical VTE prophylaxis.</p><p><strong>Main outcomes and measures: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusions and relevance: </strong>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.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11292570/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141855481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 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
{"title":"Pregnancy and Parenthood Among US Surgical Residents.","authors":"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","doi":"10.1001/jamasurg.2024.2399","DOIUrl":"10.1001/jamasurg.2024.2399","url":null,"abstract":"<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","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":null,"pages":null},"PeriodicalIF":15.7,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11255977/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626792","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}