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The cranial anatomy of blindsnakes has been markedly understudied, with the small size and relative rarity of encountering these subterranean reptiles being significant limiting factors. In this article, we re-visit the skull anatomy of the Australian southern blind snake Anilios australis Gray, 1845 using microCT data, and produce the first complete atlas for the cranial anatomy of a representative of this speciose typhlopid genus. The skull is formed by 18 paired and four unpaired elements. We here produce a bone-by-bone description of each element as well as an inner ear endocast for each of two specimens differing in skull size. This approach has revealed the presence of a highly perforated dorsal plate on the septomaxilla-a structure convergent with the cribriform plate of the mammalian ethmoid bone-and a feature previously unknown for typhlopid snakes. This detailed anatomical study will facilitate ongoing taxonomic and systematic studies in the genus Anilios as well as provide comparative data for future studies on blindsnake anatomy more broadly.

Background Post-discharge venous thromboembolism (VTE) chemoprophylaxis decreases VTEs following cancer surgery, however identifying high-risk patients remains difficult. Our objectives were to (1) identify factors available at hospital discharge associated with post-discharge VTE following hepatectomy for malignancy and (2) develop and validate a post-discharge VTE risk calculator to evaluate patient-specific risk. Methods Patients who underwent hepatectomy for malignancy from 2014 to 2017 were identified from the ACS NSQIP hepatectomy procedure targeted module. Multivariable logistic regression identified factors associated with post-discharge VTE. A post-discharge VTE risk calculator was constructed, and predicted probabilities of post-discharge VTE were calculated. Results Among 11 172 patients, 95 (0.9%) developed post-discharge VTE. Post-discharge VTE was associated with obese BMI (OR 2.29 vs. normal BMI [95%CI 1.31–3.99]), right hepatectomy/trisegmentectomy (OR 1.63 vs. partial/wedge [95%CI 1.04–2.57]), and several inpatient postoperative complications: renal insufficiency (OR 5.29 [95%CI 1.99–14.07]), transfusion (OR 1.77 [95%CI 1.12–2.80]), non-operative procedural intervention (OR 2.97 [95%CI 1.81–4.86]), and post-hepatectomy liver failure (OR 2.22 [95%CI 1.21–4.08]). Post-discharge VTE risk ranged from 0.3% to 30.2%. Twenty iterations of 10-fold cross validation identified internal validity. Conclusions Risk factors from all phases of care, including inpatient complications, are associated with post-discharge VTE following hepatectomy. Identifying high-risk patients may allow for personalized risk-based post-discharge chemoprophylaxis prescribing.

Surgical site infection after pancreaticoduodenectomy is often caused by pathogens resistant to standard prophylactic antibiotics, suggesting that broad-spectrum antibiotics may be more effective prophylactic agents. This article describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first U.S. randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials.

Objectives To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents. Background summary data Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood. Methods Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression. Results Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment. Conclusions Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.

BACKGROUND: Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use. METHODS: Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed. RESULTS: Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16–1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15–1.74), or had an open resection (aOR 1.94, 95%CI 1.49–2.53). There was notable hospital variability in drain use (range: 0% to 100% of patients), and 77.5% of measured variation in drain placement was at the hospital level. CONCLUSION: Prophylactic drains are commonly placed in both major and minor hepatectomy. While some patient factors are associated with drain use, hospital-specific patterns appear to be a major driver and represent a target for improvement.

BACKGROUND Patient utilization of public reporting has been suboptimal despite attempts to encourage use. Lack of utilization may be due to discordance between reported metrics and what patients want to know when making health care choices. OBJECTIVE The objective of this study was to identify measures of quality that individuals want to be presented in public reporting and explore factors associated with researching health care. RESEARCH DESIGN Patient interviews and focus groups were conducted to develop a survey exploring the relative importance of various health care measures. SUBJECTS Interviews and focus groups conducted at local outpatient clinics. A survey administered nationally on an anonymous digital platform. MEASURES Likert scale responses were compared using tests of central tendency. Rank-order responses were compared using analysis of variance testing. Associations with binary outcomes were analyzed using multivariable logistic regression. RESULTS Overall, 4672 responses were received (42.0% response rate). Census balancing yielded 2004 surveys for analysis. Measures identified as most important were hospital reputation (considered important by 61.9%), physician experience (51.5%), and primary care recommendations (43.2%). Unimportant factors included guideline adherence (17.6%) and hospital academic affiliation (13.3%, P

Post hepatectomy liver failure (PHLF) is associated with significant perioperative morbidity and mortality. A tool to identify patients at risk for PHLF may allow for earlier intervention to mitigate its severity and help clinicians when counseling patients. Our objective was to develop a PHLF risk calculator. Patients who underwent hepatectomy for any indication from 2014 to 2017 were identified from ACS NSQIP. A multivariable logistic regression model was developed that included preoperative and intraoperative variables. Model fit was assessed for discrimination using the C-statistic, and calibration using Hosmer and Lemeshow (HL) Chi square. Validation of the calculator was performed utilizing tenfold cross validation. Among 15,636 hepatectomy patients analyzed, the overall incidence of clinically significant PHLF was 2.8%. Preoperative patient factors associated with increased PHLF were male gender, preoperative ascites within 30 days of surgery, higher ASA class, preoperative total bilirubin greater than 1.2 mg/dl, and AST greater than 40 units/l. Disease related factors associated with PHLF included histology, and use of neoadjuvant therapy. Intraoperative factors associated with PHLF were extent of resection, open surgical approach, abnormal liver texture, and biliary reconstruction. The calculator’s C-statistic was 0.83 and the HL Chi square was 10.9 (p = 0.21) demonstrating excellent discrimination and calibration. On tenfold cross validation, the mean test group C-statistic was 0.82 and the HL p value was 0.26. We present a multi-institutional preoperative and early postoperative PHLF risk calculator, which demonstrated excellent discrimination and calibration. This tool can be used to help identify high-risk patients to facilitate earlier interventions.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) for localized neoplasms has been demonstrated to be feasible and safe. However, national adoption of the technique is poorly understood. Objectives of this study were to identify factors associated with use of minimally invasive distal pancreatectomy for localized neoplasms and assess hospital variation in MIDP utilization. METHODS: Retrospective cohort study of patients with pancreatic cysts, stage I pancreatic ductal adenocarcinoma, and stage I pancreatic neuroendocrine tumors undergoing distal pancreatectomy from the ACS NSQIP Pancreas Targeted Dataset. Factors associated with use of MIDP were identified using multivariable logistic regression and hospital-level variation was assessed. RESULTS: Analysis included 3,059 patients at 139 hospitals. Overall, 64.5% of patients underwent minimally invasive distal pancreatectomy. Patients were more likely to undergo MIDP if they had lower ASA classification (P = 0.004) or BMI ≥ 30 (P < 0.001) and less likely if they had pancreatic adenocarcinoma (P < 0.001). There was notable hospital variability in utilization (range 0 to 100% of cases). Hospital-level utilization of minimally invasive distal pancreatectomy did not appear to be driven by patient selection, as hierarchical analysis demonstrated that only 1.8% of observed hospital variation was attributable to measured patient selection factors. CONCLUSION: Utilization of MIDP for localized pancreatic neoplasms is highly variable. While some patient-level factors are associated with MIDP use, hospital adoption of MIDP appears to be the primary driver of utilization. Monitoring hospital-level use of MIDP may be a useful quality measure to monitor uptake of emerging techniques in pancreatic surgery.

BACKGROUND: Pancreatic fistula remains common, with limited ability to risk stratify patients preoperatively. The objective of this study was to identify risk factors for clinically-relevant postoperative pancreatic fistula (CR-POPF) that are routinely available in the preoperative setting. METHODS: Preoperatively available variables for all pancreaticoduodenectomies from 2014–2017 were examined using a national clinical registry. The cohort was separated into risk factor identification and internal validation subgroups. RESULTS: Among 15 033 pancreaticoduodenectomies, the CR-POPF rate was 16.7%. CR-POPF was more likely in patients that were male (odds ratio [OR], 1.51), obese (body mass index [BMI] > 30, OR, 1.97), had minimal preoperative weight loss (OR, 1.25), had a nondilated pancreatic duct (OR, 1.81), did not have diabetes, (OR, 1.80), did not receive neoadjuvant therapy (OR, 1.78), had no evidence of biliary obstruction (OR, 1.18), or had nonadenocarcinoma pathology (OR, 1.96; all P

BACKGROUND AND OBJECTIVES: Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections. METHODS: Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. RESULTS: The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach. CONCLUSION: The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.

IntroductionAlthough antibiotic prophylaxis is established in reducing postoperative surgical site infections (SSIs), the optimal antibiotic for prophylaxis in pancreatoduodenectomy (PD) remains unclear. The study objective is to evaluate if administration of piperacillin–tazobactam as antibiotic prophylaxis results in decreased 30-day SSI rate compared with cefoxitin in patients undergoing elective PD.Methods and analysisThis study will be a multi-institution, double-arm, non-blinded randomised controlled superiority trial. Adults ≥18 years consented to undergo PD for all indications who present to institutions participating in the National Surgical Quality Improvement Program Hepato-Pancreato-Biliary (NSQIP HPB) Collaborative will be included. Data collection will use the NSQIP HPB Collaborative Surgical Clinical Reviewers. Patients will be randomised to either 1–2 g intravenous cefoxitin or 3.375–4.5 g intravenous piperacillin–tazobactam within 60 min of surgical incision. The primary outcome will be 30-day postoperative SSI rate following PD. Secondary outcomes will include 30-day postoperative mortality; specific postoperative complication rate; and unplanned reoperation, length of stay, and hospital readmission. A subset of patients will have bacterial isolates and sensitivities of intraoperative bile cultures and SSIs. Postoperative SSIs and secondary outcomes will be analysed using logistic regression models with the primary predictor as the randomised treatment group. Additional adjustment will be made for preoperative biliary stent presence. Additionally, bacterial cultures and isolates will be summarised by presence of bacterial species and antibiotic sensitivities.Ethics and disseminationThis study is approved by the Institutional Review Board at Memorial Sloan Kettering Cancer Center. This trial will evaluate the effect of piperacillin–tazobactam compared with cefoxitin as antibiotic prophylaxis on the hazard of postoperative SSIs. The results will be disseminated regardless of the effect of the intervention on study outcomes. The manuscript describing the effect of the intervention will be submitted to a peer-reviewed journal when data collection and analyses are complete.Trial registration numberNCT03269994.

Importance Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout. Objectives To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness. Design, Setting, and Participants This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education–approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018. Main Outcomes and Measures Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency. Results Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition. Conclusions and Relevance In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

OBJECTIVES The aims of this study were to: (1) measure the prevalence of self-reported medical error among general surgery trainees, (2) assess the association between general surgery resident wellness (ie, burnout and poor psychiatric well-being) and self-reported medical error, and (3) examine the association between program-level wellness and objectively measured patient outcomes. SUMMARY OF BACKGROUND DATA Poor wellness is prevalent among surgical trainees but the impact on medical error and objective patient outcomes (eg, morbidity or mortality) is unclear as existing studies are limited to physician and patient self-report of events and errors, small cohorts, or examine few outcomes. METHODS A cross-sectional survey was administered immediately following the January 2017 American Board of Surgery In-training Examination to clinically active general surgery residents to assess resident wellness and self-reported error. Postoperative patient outcomes were ascertained using a validated national clinical data registry. Associations were examined using multivariable logistic regression models. RESULTS Over a 6-month period, 22.5% of residents reported committing a near miss medical error, and 6.9% reported committing a harmful medical error. Residents were more likely to report a harmful medical error if they reported frequent burnout symptoms [odds ratio 2.71 (95% confidence interval 2.16-3.41)] or poor psychiatric well-being [odds ratio 2.36 (95% confidence interval 1.92-2.90)]. However, there were no significant associations between program-level resident wellness and any of the independently, objectively measured postoperative American College of Surgeons National Surgical Quality improvement Program outcomes examined. CONCLUSIONS Although surgical residents with poor wellness were more likely to self-report a harmful medical error, there was not a higher rate of objectively reported outcomes for surgical patients treated at hospitals with higher rates of burnout or poor psychiatric well-being.

This study examines the associations of program characteristics with pass rates on the qualifying examination and certifying examination of the American Board of Surgery.

Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts.A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender.Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients' families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00).Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.

BACKGROUND AND OBJECTIVES: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies. METHODS: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models. RESULTS: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003). CONCLUSIONS: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.

OBJECTIVES: To empirically describe surgical residency program culture and assess program characteristics associated with program culture. SUMMARY BACKGROUND DATA: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture. METHODS: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed. RESULTS: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics. CONCLUSIONS: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

INTRODUCTION. Chemotherapy is increasingly administered prior to resection in patients with early-stage pancreatic adenocarcinoma, but the national prevalence of this practice is poorly understood. Our objectives were to (1) describe the utilization of upfront chemotherapy management of stage I pancreatic cancer; (2) define factors associated with the use of upfront chemotherapy and subsequent resection; and (3) assess hospital-level variability in upfront chemotherapy and subsequent resection. METHODS. The National Cancer Database was used to identify patients treated for clinical stage I pancreatic adenocarcinoma. Outcomes were receipt of upfront chemotherapy and surgical resection after upfront chemotherapy. Associations between patient/hospital factors and both initial management and subsequent resection were assessed by multivariable logistic regression. RESULTS. A total of 17,495 patients were included, with 26.6% receiving upfront chemotherapy. Upfront chemotherapy was more likely in patients who were ≥ 80 years of age (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.39–1.93), had T2 tumors (OR 2.56, 95% CI 2.36–2.78), or were treated at a low-volume center (OR 2.10, 95% CI 1.63–2.71). Among patients receiving upfront chemotherapy, only 33.5% underwent subsequent resection. Resection was more likely in patients with T1 tumors (OR 1.22, 95% CI 1.04–1.43) and in those treated at high-volume centers (OR 4.03, 95% CI 2.90–5.60). Only 20.4% of hospitals performed resection in > 50% of patients after upfront chemotherapy. CONCLUSION. Rates of surgical resection after upfront chemotherapy are relatively low, and the proportion of patients who eventually undergo resection varies considerably between hospitals. The use of surgery after upfront chemotherapy in resectable pancreatic cancer should be considered as an internal quality-of-cancer-care measure.

Background General surgery residencies continue to experience high levels of attrition. Methods Survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination. Outcomes were consideration of leaving residency, potential alternative career paths, and reasons for staying in residency. Results Among 7,409 residents, 930 (12.6%) reported considering leaving residency over the last year. Residents were more likely to consider other general surgery programs (46.2%) if PGY 2/3 (OR: 1.93, 95%CI 1.34–2.77) or reporting frequent duty hour violations (OR: 1.58, 95%CI 1.12–2.24). Consideration of other specialties (47.0%) was more likely if dissatisfied with being a surgeon (OR 2.86, 95%CI 1.92–4.26). Residents were more likely to consider leaving medicine (49.7%) if female (OR: 1.54, 95%CI 1.16–2.06) or dissatisfied with a surgical career (OR: 2.81, 95%CI 1.85–4.27). Common reasons for remaining in residency included a sense of too much invested to leave (65.3%) and career satisfaction (55.5%). Conclusion Profiles of trainees considering leaving residency exist based on factors associated with alternative careers. This may be a target for future interventions to reduce attrition.

BackgroundChemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy.MethodsPatients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression.ResultsA total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (pConclusions and relevanceThough overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.

Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure. The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status. The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p

Global biodiversity loss is a profound consequence of human activity. Disturbingly, biodiversity loss is greater than realized because of the unknown number of undocumented species. Conservation fundamentally relies on taxonomic recognition of species, but only a fraction of biodiversity is described. Here, we provide a new quantitative approach for prioritizing rigorous taxonomic research for conservation. We implement this approach in a highly diverse vertebrate group—Australian lizards and snakes. Of 870 species assessed, we identified 282 (32.4%) with taxonomic uncertainty, of which 17.6% likely comprise undescribed species of conservation concern. We identify 24 species in need of immediate taxonomic attention to facilitate conservation. Using a broadly applicable return-on-investment framework, we demonstrate the importance of prioritizing the fundamental work of identifying species before they are lost., In order to inform conservation effort, there is urgent need for rigorous taxonomic research to describe species under threat of extinction. Implementation of a new prioritization method identified 282 Australian reptile species needing taxonomic research, of which 17.6% represent undescribed species of conservation concern; this approach could be readily implemented across many faunal groups.

Importance Physician burnout is a serious issue, given its associations with physician attrition, mental and physical health, and self-reported medical errors. Burnout is typically measured in health care by assessing the frequency of symptoms in 2 domains, emotional exhaustion and depersonalization. However, the lack of a clinically diagnostic threshold to define burnout has led to considerable variability in reported burnout rates. Objective To estimate the prevalence of burnout using a range of definitions (ie, requiring symptoms in both domains or just 1) and thresholds (ie, requiring symptoms to occur weekly vs a few times per year) and examine the strength of the association of various definitions of burnout with suicidal thoughts and thoughts of attrition among general surgery residents. Design, Setting, and Participants A cross-sectional national survey of clinically active US general surgery residents administered in conjunction with the 2019 American Board of Surgery In-Training Examination assessed burnout symptoms, thoughts of attrition, and suicidal thoughts during the past year. Multivariable logistic regression models were used to assess the association of burnout symptoms with thoughts of attrition and suicidal thoughts. Values ofR2and C statistic were used to evaluate multivariable model performance. Exposures Burnout was evaluated with a 6-item, modified, abbreviated Maslach Burnout Inventory for 2 burnout domains: emotional exhaustion and depersonalization. Main Outcomes and Measures The primary outcome was prevalence of burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year. Results Among 6956 residents (a 85.6% response rate; including 3968 men [57.0%] and 4041 non-Hispanic White individuals [58.1%]) from 301 surgical residency programs, 2329 (38.6%) reported at least weekly symptoms of emotional exhaustion, and 1389 (23.1%) reported at least weekly depersonalization symptoms. Using the most common definition, 2607 general surgery residents (43.2%) reported weekly burnout symptoms on either subscale. Subtle changes in the definition of burnout selected resulted in prevalence estimates varying widely from 3.2% (159 residents; most stringent: daily symptoms on both subscales) to 91.4% (5521 residents; least stringent: symptoms a few times per year on either subscale). In multivariable models, all measures of higher burnout symptoms were associated with increased thoughts of attrition (depersonalization:R2, 0.097; C statistic, 0.717; emotional exhaustion:R2, 0.137; C statistic, 0.758; both:R2, 0.138; C statistic, 0.761) and suicidal thoughts (depersonalization:R2, 0.077; C statistic, 0.718; emotional exhaustion:R2, 0.102; C statistic, 0.750; both:R2, 0.106; C statistic, 0.751) among general surgery residents (allP Conclusions and Relevance In a national evaluation of general surgery residents, prevalence estimates of burnout varied considerably, depending on the burnout definition selected. Frequent burnout symptoms were strongly associated with both thoughts of attrition and suicide, regardless of the threshold selected. Future research on burnout should explicitly include a clear description and rationale for the burnout definition used.

For over two decades, assessments of geographic variation in mtDNA and small numbers of nuclear loci have revealed morphologically similar, but genetically divergent, intraspecific lineages in lizards from around the world. Subsequent morphological analyses often find subtle corresponding diagnostic characters to support the distinctiveness of lineages, but occasionally do not. In recent years it has become increasingly possible to survey geographic variation by sequencing thousands of loci, enabling more rigorous assessment of species boundaries across morphologically similar lineages. Here we take this approach, adding new, geographically extensive SNP data to existing mtDNA and exon capture datasets for the Gehyra australis and G. koira species complexes of gecko from northern Australia. The combination of exon-based phylogenetics with dense spatial sampling of mitochondrial DNA sequencing, SNP-based tests for introgression at lineage boundaries and newly-collected morphological evidence supports the recognition of nine species, six of which are newly described here. Detection of discrete genetic clusters using new SNP data was especially convincing where candidate taxa were continuously sampled across their distributions up to and across geographic boundaries with analyses revealing no admixture. Some species defined herein appear to be truly cryptic, showing little, if any, diagnostic morphological variation. As these SNP-based approaches are progressively applied, and with all due conservatism, we can expect to see a substantial improvement in our ability to delineate and name cryptic species, especially in taxa for which previous approaches have struggled to resolve taxonomic boundaries.

Patients with Cushing's Syndrome (CS) and Conn's Syndrome with bilateral adrenal masses pose a dilemma. Uptake of 18F-FDG by hyperfunctioning adrenal glands has not been previously reported and may help lateralize. The aim was to determine if 18F-FDG PET/CT scan could identify hyperfunctioning adrenal masses and determine a biological basis for uptake.Patients with nonfunctional adenomas (n = 9), CS (n = 11), and Conn's syndrome (n = 4) underwent an 18F-FDG PET/CT scan with a volume of interest circumscribing each mass to obtain a maximal standardized uptake value (SUVmax). Thirty-two adrenal masses were analyzed. Genome-wide expression data from an independent cohort were analyzed in nonfunctioning adenomas (n = 20), Conn's syndrome (n = 29), and CS (n = 24) focusing on GLUT genes. For genes differentially expressed, immunohistochemistry was performed on tissue samples.Cortisol-secreting masses (n = 16) had a higher average SUVmax of 5.9 compared to nonfunctioning masses (n = 11, average SUVmax 4.2) and aldosterone-hypersecreting masses (n = 5, average SUVmax 3.2) (p = 0.007). SUVmax cut-off of 5.33 had 50.0% sensitivity and 81.8% specificity in localizing a cortisol-secreting mass. GLUT3 expression was 2.19-fold higher in patients with CS compared to patients with nonfunctioning adenomas (p = 0.003) and 2.16-fold higher in patients with CS compared to Conn's syndrome (p = 0.006). GLUT3 immunohistochemistry showed 2.2-fold higher staining in CS tumor samples compared to nonfunctioning adenomas.Differential 18F-FDG PET/CT uptake was observed in patients with nonfunctioning, aldosterone-hypersecreting, and cortisol-secreting masses. GLUT3 overexpression in cortisol-secreting tumor likely accounts for the differential uptake. Future larger cohort studies will need to be conducted to determine if 18F-FDG PET/CT uptake can lateralize cortisol-secreting adrenal masses in patients with bilateral adrenal masses.

The blindsnake genus Anilios (formerly Ramphotyphlops ) is the largest and most diverse genus of snakes in Australia with 45 currently recognized species. Recent molecular genetic studies of the genus have identified high levels of cryptic diversity within many taxa, suggesting true species diversity is greatly underestimated. Anilios leptosoma is a slender blindsnake endemic to the mid-west of Western Australia. Although morphological variation has been identified within the species in the past, the systematics and true diversity remained unstudied. Here we use recent molecular data to guide a reappraisal of morphology in order to provide a taxonomic revision of the A. leptosoma species complex. We redescribe A. leptosoma and describe two new species that occur to the south of most of true A. leptosoma ’s distribution: A. systenos sp. nov. and A. obtusifrons sp. nov. Anilios systenos sp. nov. is known from the Geraldton region with the furthest record only 100 km to the north-east, a very small range for a species of snake. Anilios obtusifrons sp. nov. has an even smaller distribution, as it is only known from a small coastal area south of Kalbarri and may represent a range-restricted taxa. All species are genetically divergent from each other and can be distinguished by consistent morphological characteristics, including the shape of the snout, the termination point of the rostral cleft and number of mid-body scale rows and ventral scales.

We provide a taxonomic revision of the genus Crenadactylus , a group of very small clawless geckos from western and central Australia, with currently only one recognized species and four subspecies. Morphological comparisons were made on genotyped specimens from two recent genetic studies, then with an expanded sample to encompass all specimens to determine diagnostic characters in addition to morphological and geographic boundaries. Based on our findings, we elevate the subspecies Crenadactylus ocellatus ocellatus from south-western Australia and C. o. horni from the Central Uplands to full species. Consultation of the types of Diplodactylus ( = Crenadactylus ) bilineatus indicate they are C. ocellatus based on a dorsal pattern with intermixing of dark and pale scales not shared with any other taxa; we therefore maintain synonymy of ‘D.’ bilineatus with ‘D.’ ocellatus . We describe three new Western Australian species formerly allocated to C. o. horni : C. occidentalis sp. nov. from the western coast, C. tuberculatus sp. nov. from the Cape Range and C. pilbarensis sp. nov. from the Pilbara region. To stabilize the Kimberley taxa, we also raise C. ocellatus rostralis and C. ocellatus naso , both monophyletic taxa from the monsoonal tropics, to full species, while acknowledging further work is required on the C. naso species complex. All new species treated here possess distinctive morphological characters to diagnose them, including enlarged dorsal tubercles in C. tuberculatus sp. nov., a single enlarged supranasal in C. horni and a single enlarged postmental in C. pilbarensis sp. nov. Pattern was relatively conserved among taxa, with highly contrasting dark and pale longitudinal lines, with the exception of the type species C. ocellatus that possesses intermixed dark and pale scales and ocelli. Crenadactylus species are separated by deep genetic divergences and are usually allopatrically distributed. This indicates that despite being Australia’s smallest geckos, or possibly because of it, these diminutive lizards have a long history of localised persistence through major climatic changes over millions of years.

The desert mouse (Pseudomys desertor) is one of the most common and widespread native rodent species across arid and semiarid Australia. The species occurs in a variety of habitats and like many arid-zone rodents, its distribution and abundance is known to fluctuate with environmental conditions. Following the capture of a suspected specimen of P. desertor outside the current known range of the species, we used molecular-based methods to confirm the specimen’s identification as P. desertor. This note presents a record of the species north of Dalwallinu, Western Australia, which represents a significant range extension for the species of 324 km from the nearest confirmed record.