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Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences., (© 2024. Society of Surgical Oncology.)

The emergence of COVID-19 dramatically changed social behavior across societies and contexts. Here we study whether social norms also changed. Specifically, we study this question for cultural tightness (the degree to which societies generally have strong norms), specific social norms (e.g. stealing, hand washing), and norms about enforcement, using survey data from 30,431 respondents in 43 countries recorded before and in the early stages following the emergence of COVID-19. Using variation in disease intensity, we shed light on the mechanisms predicting changes in social norm measures. We find evidence that, after the emergence of the COVID-19 pandemic, hand washing norms increased while tightness and punishing frequency slightly decreased but observe no evidence for a robust change in most other norms. Thus, at least in the short term, our findings suggest that cultures are largely stable to pandemic threats except in those norms, hand washing in this case, that are perceived to be directly relevant to dealing with the collective threat., (© 2024. The Author(s).)

Background: A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach., Methods: We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion., Results: Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process., Conclusion: Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: The lack of family-friendly policies continues to contribute to the underrepresentation and attrition of surgical trainees. Women in surgery face unique challenges in balancing surgical education with personal and family needs., Observations: The Association of Women Surgeons is committed to supporting surgical families and developing equitable family-friendly guidelines. Herein we detail recommendations for adequate paid parental leave, access to childcare, breastfeeding support, and insurance coverage of fertility preservation and assisted reproductive technology., Conclusions and Relevance: The specific recommendations outlined in this document form the basis of a comprehensive initiative for supporting surgical families.

Background: Lack of mentorship may deter medical students who identify as underrepresented minorities (URM) from entering academic surgery., Methods: 30 mentor-medical student pairs from the AWS 2020 virtual mentorship pilot-program were surveyed pre-and post-program to explore 1) feasibility of meetings, and, 2) program's perceived efficacy in fostering professional development skills. Participants responded using a 5-point Likert scale (1 = not at all; 5 = completely). Proportions of participants in each category were compared., Results: Proportion of participants perceiving monthly meetings to be completely feasible did not differ from pre-to post-program surveys for mentees (75%(21/28) vs. 71%(12/17); p = 0.743) or mentors (71%(17/24) vs 71%(13/18); p = 1.00). Compared to pre-program responses, mentees endorsed "completely" (Likert scale 5) improving with regard to their elevator speech (p = 0.001), developing their curriculum vitae (p = 0.003), ability to network (p = 0.021), and acquiring skills for career advancement (p = 0.003)., Conclusion: Virtual mentorship may be a feasible and effective means of increasing access to mentors for URM medical students., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Through the understanding of multiple etiologies, pathologies, and disease progression trajectories, breast cancer shifted historically from a singular malignancy of the breast to a complex of molecular/biological entities, translating into individualized disease-modifying treatments. As a result, this led to various de-escalations of treatment compared with the gold standard in the era preceding systems biology: radical mastectomy. Targeted therapies have minimized morbidity from the treatments and mortality from the disease. Biomarkers further individualized tumor genetics and molecular biology to optimize treatments targeting specific cancer cells. Landmark discoveries in breast cancer management have evolved through histology, hormone receptors, human epidermal growth factor, single-gene prognostic markers, and multigene prognostic markers. Relevant to the reliance on histopathology in neurodegenerative disorders, histopathology evaluation in breast cancer can serve as a marker of overall prognosis rather than predict response to therapies. This chapter reviews the successes and failures of breast cancer research through history, with focus on the transition from a universal approach for all patients to divergent biomarker development and individualized targeted therapies, discussing future areas of growth in the field that may apply to neurodegenerative disorders., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Peer review is a learned skill set that requires knowledge of study design, review construct, ethical considerations, and general expertise in a field of study. Participating in peer review is a rewarding and valuable experience in which all academic physicians are encouraged to partake. However, formal training opportunities in peer review are limited. In 2021, the Association of Women Surgeons and the journal Surgery collaborated to develop a Peer Review Academy. This academy is a 1-year longitudinal course that offers a select group of young women surgical trainees across all specialties a curriculum of monthly lectures and multiple formal mentored peer review opportunities to assist them in developing the foundation necessary to transition to independent peer review. The trainees and faculty mentors participating in the Association of Women Surgeons-Surgery Peer Review Academy compiled a summary of best peer review practices, which is intended to outline the elements of the skill set necessary to become a proficient peer reviewer., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Autologous free tissue transfer is a common method of breast reconstruction in the United States, but it involves many care teams and can incur a large cost on an institution. The consistency and efficiency of performing these procedures can be improved with a method called the 4 disciplines of execution (4DX)., Methods: Patients that underwent autologous breast reconstruction between 2015 and 2020 were included. Midway through the collection period, several preoperative and intraoperative interventions were implemented using the 4DX. Then, 2 cohorts of patients were analyzed for differences in operative times, length of stay (LOS), and major complications., Results: Thirty-two total patients were included. The median operative time before interventions were implemented was 828 minutes, and the median operative time after interventions was 619 minutes (P < 0.05). The median LOS in days before interventions was 5 days, and the median LOS after interventions was 3 days (P < 0.05). There were no statistically significant differences in complications before or after the interventions., Conclusions: The 4DX successfully improved consistency and efficiency in the process of performing autologous breast reconstruction at our institution, as evidenced by a faster median operative time and shorter patient LOS in the hospital., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Latin America is the region with the highest prevalence of overweight and obesity, therefore, strategies and policies have been implemented in some countries to reduce this health problem. Among these, fiscal policies, such as taxes on sugary drinks, high-calorie products, the regulation of advertising and food labeling., Objective: To describe the main strategies and policies against obesity, and the effect they have had on the population., Material and Methods: A search was made for articles in English and Spanish published in Pubmed, Scielo, Google Scholar. The keywords were included: health policies, nutritional labeling in Latin America, food labeling, tax on sugary drinks and non-basic foods with high energy density., Results: Within the strategies, traffic light labeling, and warning labeling were the most accepted and understood. As for the taxation of sugar sweetened beverages, studies showed a positive effect on the reduction of consumption, purchase and sale, as well as a decrease in purchases of non-essential energy-dense foods. However, nutritional education in vulnerable groups is essential to better understand their interpretation., Conclusions: The studies analyzed suggest that food labeling, sugar sweetened beverages and non-essential energy-dense foods taxes could effectively reduce the prevalence of overweight and obesity in the population in the long term, as well as the costs associated with these diseases., (© 2022 Revista Médica del Instituto Mexicano del Seguro Social.)

The COVID-19 pandemic (and its aftermath) highlights a critical need to communicate health information effectively to the global public. Given that subtle differences in information framing can have meaningful effects on behavior, behavioral science research highlights a pressing question: Is it more effective to frame COVID-19 health messages in terms of potential losses (e.g., "If you do not practice these steps, you can endanger yourself and others") or potential gains (e.g., "If you practice these steps, you can protect yourself and others")? Collecting data in 48 languages from 15,929 participants in 84 countries, we experimentally tested the effects of message framing on COVID-19-related judgments, intentions, and feelings. Loss- (vs. gain-) framed messages increased self-reported anxiety among participants cross-nationally with little-to-no impact on policy attitudes, behavioral intentions, or information seeking relevant to pandemic risks. These results were consistent across 84 countries, three variations of the message framing wording, and 560 data processing and analytic choices. Thus, results provide an empirical answer to a global communication question and highlight the emotional toll of loss-framed messages. Critically, this work demonstrates the importance of considering unintended affective consequences when evaluating nudge-style interventions., Competing Interests: Conflict of InterestThe authors declare no conflict of interest., (© The Society for Affective Science 2022.)

Introduction: CHDs are the most common type of birth defect. One in four newborns with a heart defect has a critical CHD. In Mexico, there is a lack of data available to determine its prevalence. Pulse oximetry screening programmes have been implemented worldwide, reporting opportunity areas in algorithm interpretation and data management. Our study aims to share preliminary results of a 3-year experience of a multicentre pulse oximetry screening programme that addresses critical challenges., Materials and Methods: This retrospective study examined the reports of newborns screened from February 2016 to July 2019 from five hospitals. Two algorithms -the New Jersey and the American Academy of Pediatrics- were implemented over consecutive periods. The algorithms' impact was assessed through the calculation of the false-positive rate in an eligible population., Results: A total of 8960 newborns were eligible for the study; from it, 32.27% were screened under the New Jersey and 67.72% under the American Academy of Pediatrics algorithm - false-positive rate: 1% (CI 95: ± 0.36%) and 0.71% (CI 95: ± 0.21%), respectively. Seventy-nine newborns were referred, six were diagnosed with critical CHD, and six with CHD. The critical CHD estimated prevalence was 6.69:10,000 newborns (CI 95: ± 5.36). Our results showed that the algorithm was not related to the observable false-positive rate reduction., Discussion: Other factors may play a role in decreasing the false-positive rate. Our experience implementing this programme was that a systematic screening process led to more confident results, newborn's report interpretation, and follow-up.

To tackle the spread of COVID-19, governments worldwide have implemented restrictive public health behavioural measures. Whether and when these measures lead to positive or negative psychological outcomes is still debated. In this study, drawing on a large sample of individuals (N total  = 89,798) from 45 nations, we investigated whether the stringency of public health measures implemented at the outset of the COVID-19 pandemic in March-May 2020 was associated with individuals' levels of stress and compliance. Moreover, we addressed the question of how these associations may be moderated by the measures' implementation lag, nations' tolerance for unequal distributions of power (i.e., power distance), and individuals' institutional trust. Linear mixed models suggested that slower implementation of less stringent measures was associated with higher stress and lower compliance. Also, rapid implementation of stricter measures was associated with a mild increase in stress. Such effects were especially pronounced in countries with less tolerance for inequality. Albeit significant, the moderating effect of institutional trust was very small. The results suggest that it may be important to consider the measures' implementation lag when tackling the spread of COVID-19, but findings should be interpreted in relation to the data collection period., (© 2021 The British Psychological Society.)

The study of moral judgements often centres on moral dilemmas in which options consistent with deontological perspectives (that is, emphasizing rules, individual rights and duties) are in conflict with options consistent with utilitarian judgements (that is, following the greater good based on consequences). Greene et al. (2009) showed that psychological and situational factors (for example, the intent of the agent or the presence of physical contact between the agent and the victim) can play an important role in moral dilemma judgements (for example, the trolley problem). Our knowledge is limited concerning both the universality of these effects outside the United States and the impact of culture on the situational and psychological factors affecting moral judgements. Thus, we empirically tested the universality of the effects of intent and personal force on moral dilemma judgements by replicating the experiments of Greene et al. in 45 countries from all inhabited continents. We found that personal force and its interaction with intention exert influence on moral judgements in the US and Western cultural clusters, replicating and expanding the original findings. Moreover, the personal force effect was present in all cultural clusters, suggesting it is culturally universal. The evidence for the cultural universality of the interaction effect was inconclusive in the Eastern and Southern cultural clusters (depending on exclusion criteria). We found no strong association between collectivism/individualism and moral dilemma judgements., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: This manuscript describes the implementation of a Virtual Reality (VR) recreation program at long-term care sites across Ontario, Canada, using the RE-AIM Framework to guide the implementation and its evaluation., Methods: We developed a VR recreation program to enhance the lives of long-term care residents, through 3 sequential phases. In Phase 1, we learned about resident and staff needs through focus groups, staff surveys and observations. In Phase 2, we developed 10 VR experiences, based on the data from Phase 1. In Phase 3, we implemented the VR experiences and supporting manual and measured their implementation, using the RE-AIM Framework., Results: We found the VR program to be highly (but not consistently) implementable across all sites. Factors that supported implementation were the following: resident interest in the content and technology, relative ease of use for staff to implement and formally integrating VR into the recreation calendar. Factors that impeded implementation were the following: the size of the headset, inability for the headset to cast given the sites' Information Technology infrastructure and some content that was not engaging., Conclusions: VR programs are highly implementable and this implementation is enhanced by integration of the program into existing recreational systems, ease of use and resident engagement., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Introduction: This paper describes the findings of a pilot implementation project that explored the potential of virtual reality (VR) technology in recreational programming to support the well-being of older adults in long-term care (LTC) homes., Methods: 32 Adults in four LTC homes participated in a pilot implementation project where they viewed VR experiences of popular locations in Canada created especially for this project. Data in this paper are based on multiple viewing experiences ( n = 102) over a two-week period., Results: VR appeared to be an effective distraction from pain for the participants. Participants of this study found the VR experiences to be enjoyable and were relaxed and happy while viewing them. Most participants were attentive or focused while viewing the VR experiences, and the experiences were found to be a source of reminiscence for some of the participants. Participants related well to others around them during a majority of the experiences and the VR experiences were a point of conversation between the staff and the participants., Conclusion: The findings from this pilot implementation reveal that VR shows potential to enhance the physical, emotional, cognitive, and social well-being of older adults living in LTC, including those living with cognitive impairment., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: Sentinel Lymph Node Biopsy (SLNB) is standard of care for women with clinically N0 breast cancer. However, there are no randomized controlled studies in men determining optimal surgical axillary management., Methods: Using the National Cancer Database, males diagnosed from 2006-2016 with clinical T1-4 N0 tumors treated with primary surgery were identified and categorized by axillary management. Clinicopathologic variables were compared between two timeframes, 2006-2011 and 2012-2016. Survival analysis was performed., Results: We identified 2,646 males meeting criteria. Use of SLNB increased (65.9%-72.8%, P < 0.01). For those who underwent ALND, administration of radiation (31.1% versus 48.8%, P < 0.01) and endocrine therapy (70.2% versus 80.7%, P < 0.01) increased. There was no difference in survival between timeframes (P = 0.42). For those who underwent SLNB, tumor grade (P = 0.02) and pathologic T stage (P < 0.01) were higher and more patients underwent mastectomy (74.9% versus 79.4%, P = 0.02). Administration of chemotherapy decreased (35.1% versus 27.2%, P < 0.01) and endocrine therapy increased (72.1% versus 81.3%, P < 0.01). Survival of those who underwent sentinel lymph node biopsy (SLNB) diagnosed 2012-2016 was worse than those diagnosed 2006-2011 (P = 0.01)., Conclusions: Use of SLNB alone has increased while ALND has declined in males with clinically N0 breast cancer. However, patients who underwent SLNB alone in the later time period had worse clinical characteristics and experienced differences in adjuvant therapy. This suggests increased acceptance of the use of SLNB for axillary management. Further analysis is warranted to evaluate methods of axillary staging and the impact on outcomes in males with breast cancer., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Cystic fibrosis (CF) is an autosomal recessive disorder caused by pathogenic variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The CF variants incidence is highly variable and even undetermined in some countries like Mexico., Methods: In this study, the allele frequencies of 361 variants in the CFTR gene were investigated in 1455 Mexicans without a CF or CFTR-related disorders (CFTR-RD) diagnosis. We also performed a statistical comparative analysis against allele frequencies of different populations to measure genetic differences in the prevalence of CFTR variants., Results: In the vast majority of cases, the allele frequencies of this cohort were comparable to those found in other populations. However, some variants displayed significant differences in their allele frequencies when compared with European and African populations., Conclusions: This study provides information about CFTR variants to predict the prevalence of CF in Mexico and uncover other unknown but frequent pathogenic variants in the country. Additionally, other CFTR-RD variants have also been studied using population data of the same CFTR variants. Studies like this could help develop a regional molecular diagnostic screen to optimize the medical care of CF patients., (© 2021. The Author(s).)

Competing Interests: AUTHOR DISCLOSUREDrs Sánchez-Espino, Gil-Téllez, Cantú-Reyna, and Martínez-Longoria have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Humans are social animals, but not everyone will be mindful of others to the same extent. Individual differences have been found, but would social mindfulness also be shaped by one's location in the world? Expecting cross-national differences to exist, we examined if and how social mindfulness differs across countries. At little to no material cost, social mindfulness typically entails small acts of attention or kindness. Even though fairly common, such low-cost cooperation has received little empirical attention. Measuring social mindfulness across 31 samples from industrialized countries and regions ( n = 8,354), we found considerable variation. Among selected country-level variables, greater social mindfulness was most strongly associated with countries' better general performance on environmental protection. Together, our findings contribute to the literature on prosociality by targeting the kind of everyday cooperation that is more focused on communicating benevolence than on providing material benefits., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Purpose: Previous studies have suggested axillary lymph node dissection (ALND) can be omitted in early breast cancer patients undergoing mastectomy with positive lymph nodes (LNs). We assessed the national utilization of ALND and overall survival (OS) for larger, locally advanced tumors in patients undergoing mastectomy with positive LNs., Methods: The National Cancer Database from 2006 to 2016 was queried for mastectomy patients with clinical T3/T4, N0 tumors, and 1-2 positive LNs. Trends and outcomes for ALND were compared to sentinel lymph node biopsy (SLNB) alone., Results: Thousand nine hundred and seventeen women were included. The proportion of ALND decreased from 70% pre-Z0011 to 52% post-Z0011. On Kaplan-Meier analysis, ALND had better OS compared to SLNB alone (p < 0.01). On multivariate analysis, age (p < 0.01), chemotherapy (p < 0.01), and hormonal therapy (p < 0.01) were associated with better OS. In patients who received adjuvant radiation therapy (ART) ALND improved OS on multivariate analysis (p < 0.01)., Conclusion: This is the first large database study to demonstrate a national trend to forego ALND in mastectomy patients with large or locally advanced tumors (T3/T4abc) and 1-2 positive lymph nodes. This study suggests a survival benefit for ALND, particularly in patients receiving ART. Careful consideration and further investigations should be performed prior to omitting ALND this patient population., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The COVID-19 pandemic has increased negative emotions and decreased positive emotions globally. Left unchecked, these emotional changes might have a wide array of adverse impacts. To reduce negative emotions and increase positive emotions, we tested the effectiveness of reappraisal, an emotion-regulation strategy that modifies how one thinks about a situation. Participants from 87 countries and regions (n = 21,644) were randomly assigned to one of two brief reappraisal interventions (reconstrual or repurposing) or one of two control conditions (active or passive). Results revealed that both reappraisal interventions (vesus both control conditions) consistently reduced negative emotions and increased positive emotions across different measures. Reconstrual and repurposing interventions had similar effects. Importantly, planned exploratory analyses indicated that reappraisal interventions did not reduce intentions to practice preventive health behaviours. The findings demonstrate the viability of creating scalable, low-cost interventions for use around the world. PROTOCOL REGISTRATION: The stage 1 protocol for this Registered Report was accepted in principle on 12 May 2020. The protocol, as accepted by the journal, can be found at https://doi.org/10.6084/m9.figshare.c.4878591.v1., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

The COVID-19 pandemic has caused a profound change in health organizations at both the primary and hospital care levels. This cross-sectional study aims to investigate the impact of the COVID-19 pandemic in the annual rate of new cancer diagnosis in two university-affiliated hospitals. This study includes all the patients with a pathological diagnosis of cancer attended in two hospitals in Málaga (Spain) during the first year of pandemic. This study population was compared with the patients diagnosed during the previous year 2019. To analyze whether the possible differences in the annual rate of diagnoses were due to the pandemic or to other causes, the patients diagnosed during 2018 and 2017 were also compared. There were 2340 new cancer diagnosis compared to 2825 patients in 2019 which represented a decrease of -17.2% ( p = 0.0001). Differences in the number of cancer patients diagnosed between 2018 and 2019 (2840 new cases; 0.5% increase) or 2017 and 2019 (2909 new cases; 3% increase) were not statistically significant. The highest number of patients lost from diagnosis in 2020 was in breast cancer (-26.1%), colorectal neoplasms (-16.9%), and head and neck tumors (-19.8%). The study of incidence rates throughout the first year of the COVID-19 pandemic shows that the diagnosis of new cancer patients has been significantly impaired. Health systems must take the necessary measures to restore pre-pandemic diagnostic procedures and to recover lost patients who have not been diagnosed.

Norm enforcement may be important for resolving conflicts and promoting cooperation. However, little is known about how preferred responses to norm violations vary across cultures and across domains. In a preregistered study of 57 countries (using convenience samples of 22,863 students and non-students), we measured perceptions of the appropriateness of various responses to a violation of a cooperative norm and to atypical social behaviors. Our findings highlight both cultural universals and cultural variation. We find a universal negative relation between appropriateness ratings of norm violations and appropriateness ratings of responses in the form of confrontation, social ostracism and gossip. Moreover, we find the country variation in the appropriateness of sanctions to be consistent across different norm violations but not across different sanctions. Specifically, in those countries where use of physical confrontation and social ostracism is rated as less appropriate, gossip is rated as more appropriate.

Background: The influence of social media and Twitter in general surgery research, mentorship, networking, and education is growing. Limited data exist regarding individuals who control the dialogue. Our goal was to characterize influencers leading the discussion in general surgery., Methods: Right Relevance Insight API was searched for "general surgery," and individual influencers were ranked by a comprehensive assessment of connections (followers/following) and engagement (likes, retweets, and comments). Profession, specialty, gender, and location were collected utilizing Twitter, Doximity, LinkedIn, ResearchGate, and institutional websites. American Board of Surgery and Royal College of Physicians and Surgeons of Canada were queried for board certification and academic h -index scores were acquired from Scopus., Results: Eighty-eight individual influencers in general surgery were identified, with 73 holding positions in general surgery. Attending level general surgeons comprised 50%, of which 91% are board certified, and 94% completed a fellowship (surgical oncology, laparoscopic surgery, critical care/trauma, and colorectal surgery). Residents comprised 31%; 11% were nonsurgeons and 3% were not physicians. The majority of residents and fellow influencers were female (72%). Many general surgery influencers were international (51%), particularly Canadian (28% overall). The academic h -indices for these influencers (n = 73) ranged from 0 to 73 (mean 14.5 ± 8.2; median 9.5)., Discussion: Our data describe the positions, backgrounds, and research contributions of the top Twitter influencers in general surgery. Those engaged in social media should consider the background, expertise, and motivation of these influencers as the utilization and impact of this platform grows.

Background: Negotiation is an essential professional skill. Surgeons negotiating new roles must consider: 1) career level (e.g., new graduate, mid-career or leadership), 2) practice environment (e.g., academic, private practice), 3) organization (e.g., academic, university-affiliated, specialized center), and 4) work-life needs (e.g., geography, joint recruitment)., Methods: A review of the literature related to surgical job negotiation was conducted. Expert opinion was also sought., Results: Current data and experience suggest that negotiation must be tailored to practice type, surgeon experience/skill set and should always occur with the advice of legal counsel. Understanding principled negotiation and engaging in preparation and practice will also improve negotiation skills., Conclusions: Our findings shed light on common blind spots among surgeons negotiating new professional roles and provide guidance on optimizing job negotiation skills., Competing Interests: Declaration of competing interest The authors have no conflict of interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The ACOSOG Z0011 trial has essentially eliminated axillary lymph node dissection (ALND) in breast conserving therapy (BCT) patients with clinical T1/T2 and 1-2 positive sentinel lymph nodes (SLNs). Currently, ALND is recommended for positive SLNs unless ACOSOG Z0011 criteria are applicable. We aimed to assess the national trends and axillary management before and after the publication of ACOSOG Z0011 for larger tumors., Methods: An IRB-approved study evaluated the National Cancer Database from 2006 to 2016. Women with clinical T3/T4, N0 who otherwise fit ACOSOG Z0011 criteria were included. Neoadjuvant systemic therapy or known nodal disease was excluded. Clinicopathologic data were compared between two timeframes based on ACOSOZ Z0011 publication and by axillary management. Patients were categorized into SLNB alone (1-5 lymph nodes examined) and ALND (≥10 lymph nodes examined) groups., Results: A total of 230 women fit inclusion criteria, of whom 36% underwent ALND. ALND use decreased from 54% in 2006 to 14% in 2016 (P < 0.01). Comparing ALND to SLNB alone within the pre-Z0011 era, comprehensive community cancer programs had higher proportions of ALND, whereas academic centers had higher rates of SLND alone (P = 0.03). Comparing similar axillary management between eras, SLNB-alone patients in the post-Z0011 era had higher pT and pN stages, were less likely to be Her2 positive, and were more likely to receive systemic treatment., Conclusions: There is a national trend to forgo ALND in women who have tumors larger than those included in the Z0011 criteria without any clear clinicopathologic indications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The evolving landscape of academic surgery demands leaders who are not only effective clinicians and researchers, but also administrators able to navigate complex hospital organizations, financial pressures in the era of quality measures, and inclusion of an increasingly diverse workforce. The aim of this study was to characterize achievements and assess perspectives in becoming a surgical chair in order to guide young surgeons in their career trajectories to surgical leadership., Methods: A survey encompassing demographics, surgical training, nonmedical advanced degrees, academic advancement, and leadership experiences was sent via electronic mail to members of the American College of Surgeons Society of Surgical Chairs in December 2018., Results: Of 191 Society of Surgical Chairs members, 52 (27.2%) completed the survey, with 6 (11.5%) women, 40 (76.9%) white, and the majority becoming chair between ages 46 and 60 (n = 39, 75.0%). Training beyond residency included fellowships (n = 41, 78.8%) and advanced nonmedical degrees (n = 15, 28.8%). Median H-index was 47 (range 10-120) with 126 (5-500) research publications, and grants received was 2 (0-38) for federal and 5 (0-43) for industry. Female chairs appear to have fewer nonmedical degrees (n = 1) and no difference in age at becoming chair (66.7% vs 79.6% between ages 46 and 60), H-index (26 [10-41] vs 49 [17-120]), or publications (93 [10-189] vs 150 [5,500]). Prior educational (n = 36, 69.2%) and clinical (n = 44, 84.6%) leadership roles were common, with 30 chairs (57.7%) having held both roles. Experiences which respondents felt have most helped them function as chair included serving as a clinical division director (n = 37, 71.2%), residency program director (n = 28, 53.8%), leadership courses (n = 28, 53.8%), a research career (n = 22, 42.3%), and being a vice/interim chair (n = 15, 28.8%). Personal traits felt to be most important in becoming a successful chair included being effective at communication (n = 37, 71.2%), collaborative (n = 35, 67.3%), trustworthy (n = 30, 57.7%), and a problem-solver (n = 27, 51.9%)., Conclusion: Becoming a department surgical chair often involves not only surgical subspecialty expertise, but also nonmedical training and prior leadership roles, which help facilitate development of skills integral to navigating the collaborative and diverse nature of academic surgery in the current era., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The relationships between subjective status and perceived legitimacy are important for understanding the extent to which people with low status are complicit in their oppression. We use novel data from 66 samples and 30 countries ( N  = 12,788) and find that people with higher status see the social system as more legitimate than those with lower status, but there is variation across people and countries. The association between subjective status and perceived legitimacy was never negative at any levels of eight moderator variables, although the positive association was sometimes reduced. Although not always consistent with hypotheses, group identification, self-esteem, and beliefs in social mobility were all associated with perceived legitimacy among people who have low subjective status. These findings enrich our understanding of the relationship between social status and legitimacy., Competing Interests: There are no conflicts of interest to report., (© 2020 The Authors. European Journal of Social Psychology published by John Wiley & Sons Ltd.)

Introduction: A 2014 consensus statement from the Society of Surgical Oncology and American Society for Radiation Oncology supported "no ink on tumor" as an adequate margin for breast conserving therapy (BCT). This study evaluates this statement in a multi-institution cohort., Methods: A retrospective review of BCT cases at 3 comprehensive cancer centers was performed. Women age >18 receiving BCT for T1-2 breast cancer from 2008-2012 were included. Pre-2014, all sites considered 2 mm adequate. Estimated re-excision rates using the 2014 guidelines were calculated and factors predictive of re-excision were analyzed., Results: 542 patients (545 lumpectomies) were eligible. Using a ≥2 mm margin standard, 32.8% of patients underwent re-excision compared to 14.1% after 2014 (p < 0.0001). Tumor size (p= 0.003), grade (p=0.015), and lymphovascular invasion (p=0.021) were predictive of re-excision. Patients with additional intraoperative margins excised were less likely to require reoperation (p=0.002). Local recurrence was unaffected by re-excision after mean followup of 66 months., Conclusions: The 2014 margin guidelines markedly reduce re-excision rates. There is no difference in local recurrence for patients after re-excision for a close margin versus without Powered., Competing Interests: Declaration of competing interest The authors whose names are listed have NO conflict of interest., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

BACKGROUND Hereditary spastic paraplegia (HSP or SPG) consists of a heterogeneous group of disorders, clinically divided into pure and complex forms. The former is characterized by neurological impairment limited to lower-extremity spasticity. The latter presents additional symptoms such as seizures, psychomotor impairment, cataract, deafness, and peripheral neuropathy. The genetic structure of HSP is diverse, with more than 72 loci and 55 genes identified so far. The most common type is SPG4, accounting for 40% of cases. This case report describes 2 siblings presenting SPG4, one presumptive and one confirmed with a homozygous SPAST variant. CASE REPORT Two siblings born to third-degree consanguineous and healthy parents presented a SPG4 complex phenotype characterized by progressive psychomotor deterioration, mixed seizure patterns, corneal opacity, dysostotic bones, limb spasticity with extensor plantar responses, and axial hypotonia. After ruling out most inborn errors of metabolism in one of the patients, the complexity of the case derived from exome sequencing. The identification of a homozygous variant in the SPAST gene established a diagnosis for SPG4. The phenotype-genotype did not correlate to classical manifestations, most likely due to the variant's zygosity. Moreover, 34 patient's relatives were identified with SPG4 clinical manifestations or asymptomatic with the same genetic variant in heterozygous state. CONCLUSIONS We described visual loss and seizures for SPG4 complex phenotype associated with a homozygous variant in the SPAST gene. This diagnosis will lead clinicians to consider it as a differential diagnosis providing adequate genetic counseling.

Background: Elaborate an updated guideline of recommendations for the safe return to elective orthopedic surgery post COVID-19 pandemic., Methods: Bibliographic review of relevant global literature., Results: Recommendation guidelines with appropriate definitions of orthopedic elective surgery, correct contagion risk stratification for COVID-19, considerations for specific risk groups, hospital adaptations and anesthetic, intraoperative and postoperative special care for a safe restart of orthopedic elective surgery post COVID-19 pandemic., Conclusions: The safe restart of orthopedic elective surgery is possible as long as we take into consideration the appropriate recommendations, which we have summarized in this review.

Hawkinsinuria is an autosomal dominant disorder of tyrosine metabolism. Mutations in the 4-hydroxyphenylpyruvate dioxygenase gene ( HPD ) result in an altered HPD enzyme, causing hawkinsin and tyrosine accumulation. Persistent metabolic acidosis and failure to thrive are common features in patients with hawkinsinuria. We present the first known Latin American patient diagnosed with hawkinsinuria, and the tenth reported patient in the literature. We aim to establish clinical practice guidelines for patients with hawkinsinuria. The patient's plasma tyrosine level was 21.5 mg/dL, which is several times higher than the reference value. Mutation analysis indicated heterozygosity for V212M and A33T variants in HPD . In the case of altered tyrosine levels found during newborn screening, we propose exclusive breastmilk feeding supplemented with ascorbic acid. Amino acid quantification is useful for monitoring treatment response. If tyrosinemia persists, protein intake must be decreased via a low-tyrosine diet. Molecular studies can be used to confirm a patient's disease etiology. Further reports are required to elucidate new pathogenic and phenotypic variations to enable the development of an appropriate therapeutic approach.

The intellectual disability syndrome characterized by seizures and dysmorphic features was initially described in 2017 and was associated with genetic variants in the OTUD6B gene, identified by exome sequencing (ES) in a large cohort. This multisystem disorder primarily affects the central nervous system, the gastrointestinal, and the skeletal systems. In this article, we describe the first Mexican patient diagnosed by ES. The homozygous c.433C>T (p.Arg145*) variant of the OTUD6B gene confirmed this intellectual disability syndrome. In addition to seizures and other more frequently reported manifestations of this condition, this is the third patient with associated hypothyroidism and hypogammaglobulinemia, underscoring the value of screening for these conditions in other patients. The current challenge with this patient is to ensure medical management of his seizures and provide him with a better quality of life. The possibilities of additional therapeutic approaches may increase by understanding the physiopathology of the involved pathways.