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Winnie Yeo,1 Nicole TY Ngai,1 Christopher CH Yip,1 Frankie KF Mo,1 Victoria A Yeo,1 Jonathan WH Ko,1 Leung V Li,1 Thomas KH Lau,1 Kwai Tung Lai,1 Elizabeth Pang,1 Claudia HW Yip,1 Horatio L Yeo,1 Carol Chi Hei Kwok,2 Stephanie WY Ko,1 Alex Molassiotis3 1Department of Clinical Oncology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, People’s Republic of China; 2Department of Clinical Oncology, Princess Margaret Hospital, Kowloon, Hong Kong, People’s Republic of China; 3School of Nursing, The Hong Kong Polytechnic University, Hong KongCorrespondence: Winnie Yeo, Department of Clinical Oncology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, People’s Republic of China, Email winnieyeo@cuhk.edu.hkPurpose: Although risk factors related to chemotherapy-induced nausea and vomiting (CINV) have been identified in previous studies, only a few studies have evaluated the risk factors associated with contemporary antiemetic prophylaxis, including olanzapine/aprepitant- or NEPA-containing regimens. This study aimed to identify the risk factors associated with CINV development in Chinese breast cancer patients receiving doxorubicin and cyclophosphamide chemotherapy.Methods: Data from 304 patients enrolled in 3 previously reported prospective antiemetic studies were included. Multivariate logistic regression models were used to predict risk factors associated with CINV occurrence. Additionally, the likelihood of treatment failure in relation to the number of risk factors in individual patients was evaluated.Results: Multivariate analysis of the entire study group revealed that obesity status (defined as body mass index/= 25.0 kg/m2) and the use of olanzapine/aprepitant- or NEPA-containing anti-emetic regimens were associated with a high likelihood, while a history of motion sickness was associated with a lower likelihood, complete response (CR), and “no nausea” in the overall phase. A history of vomiting during pregnancy was also associated with a lower likelihood of an overall CR. Patients with an increasing number of risk factors had a higher likelihood of treatment failure and shorter time to first vomiting. Those who did not achieve CR and “no nausea” in the first cycle were less likely to achieve these parameters in the subsequent cycle of chemotherapy.Conclusion: The present study confirmed previously reported risk factors for CINV in Chinese breast cancer patients receiving doxorubicin and cyclophosphamide. Further optimization of CINV control is required for patients with identifiable risk factors; olanzapine/aprepitant- or NEPA- containing prophylaxis are the preferred contemporary anti-emetics regimens for Chinese breast cancer patients undergoing doxorubicin and cyclophosphamide chemotherapy.Keywords: cytotoxic, nausea and vomiting, olanzapine, aprepitant, NEPA

Competing Interests: Conflicts of Interest and Source of Funding: JAS is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by Novo Nordisk, Astra Zeneca and Eli Lilly. Institutional research funding is received from Exelixis and Eli Lilly. HY is a medical consultant for Survivornet.

Introduction: Efforts have been made to increase the number of women and physicians who are underrepresented in medicine (UIM). However, surgery has been slow to diversify, and there are limited data surrounding the impact of intersectionality., Objective: To assess the combined association of race and ethnicity and sex with rates of promotion and attrition among US academic medical department of surgery faculty., Design, Setting, and Participants: This was a retrospective cohort study using faculty roster data from the Association of American Medical Colleges. All full-time academic department of surgery faculty with an appointment any time from January 1, 2005, to December 31, 2020, were included. Study data were analyzed from September 2022 to February 2023., Exposures: Full-time academic faculty in a department of surgery with a documented self-reported race, ethnicity, and sex within the designated categories of the faculty roster of Association of American Medical Colleges., Main Outcomes and Measures: Trends in race and ethnicity and sex, rates of promotion, and rates attrition from 2010 to 2020 were assessed with Kaplan-Meier and Cox time-to-event analyses., Results: A total of 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 institutions were included. The mean (SD) program percentage of UIM male faculty increased from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty members increased from 2.3% (2.6%) to 3.3% (2.5%) over the 10-year period (P < .001). The mean program percentage of non-UIM females increased at every rank (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all P < .001). There was no change in the mean program percentage of UIM female instructors or full professors. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%) and 1.6% (3.2%) to 2.2% (3.4%), respectively (P =.002). There was no change in the mean program percentage of UIM male instructors, associate, or full professors. Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). Non-UIM males had the shortest median (IQR) time to promotion, whereas non-UIM females had the longest (6.9 [6.8-7.0] years vs 7.2 [7.0-7.6] years, respectively; P < .001). After 10 years, 79% of non-UIM males (13 202 of 16 299), 71% of non-UIM females (3784 of 5330), 68% of UIM males (1738 of 2538), and 63% of UIM females (625 of 999) remained on the faculty. UIM females had a higher risk of attrition compared with non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001) and UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .05). The mean (SE) time to attrition was shortest for UIM females and longest for non-UIM males (8.2 [0.14] years vs 9.0 [0.02] years, respectively; P < .001)., Conclusion and Relevance: Results of this cohort study suggest that intersectionality was associated with promotion and attrition, with UIM females least likely to be promoted and at highest risk for attrition. Further efforts to understand these vulnerabilities are essential.

Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons., Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender., Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience., Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons., Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals., Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Major innovation into how we pursue diagnosis and therapies for gastrointestinal (GI) diseases is urgently needed to seek better, less invasive, and less costly innovations in diagnostic and therapeutic interventions in the GI tract. Learning from prior paradigm shifts in cardiac and vascular we present here several initial steps we have undertaken to follow the endoluminal path, using advanced imaging methods, including endoscopy, and data management with avoidance of entry into a body cavity when possible. We will review the benefit and ease of incorporating routine fluoroscopy with endoscopy to improve safety and efficiency. We describe the development of "hybrid" procedure rooms for GI interventions and rationale for their use. We also emphasize the importance of collaborating with interventional radiologists, software engineers, and data specialists. We predict major improvement in outcomes in both diagnosis and treatment will follow., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

The use of social media platforms in a professional capacity has grown and presents unique opportunities for women surgeons. Women surgeons face unique obstacles and challenges compared with their male counterparts. Social media has helped women surgeons create an online community and has provided opportunities for mentorship and professional advancement. In addition, it has helped break down traditional constructs of what it means to be a surgeon and allowed the medical community and public to view images of a modern surgeon. Social media has played an important role in continually increasing efforts to diversify the field of surgery and break down traditional stereotypes associated with surgeons. However, there are some downsides of social media that women surgeons need to be aware of, particularly, the risk of harassment, criticism, and potentially harmful online reviews., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Japanese encephalitis virus (JEV) is an important arbovirus in Asia that can cause serious neurological disease. JEV is transmitted by mosquitoes in an enzootic cycle involving porcine and avian reservoirs, in which humans are accidental, dead-end hosts. JEV is currently not endemic in Singapore, after pig farming was abolished in 1992; the last known human case was reported in 2005. However, due to its location along the East-Asian Australasian Flyway (EAAF), Singapore is vulnerable to JEV re-introduction from the endemic regions. Serological and genetic evidence in the last decade suggests JEV's presence in the local fauna. In the present study, we report the genetic characterization and the first isolation of JEV from 3214 mosquito pools consisting of 41,843 Culex mosquitoes, which were trapped from April 2014 to May 2021. The findings demonstrated the presence of genotype I of JEV (n = 10), in contrast to the previous reports of the presence of genotype II of JEV in Singapore. The genetic analyses also suggested that JEV has entered Singapore on several occasions and has potentially established an enzootic cycle in the local fauna. These observations have important implications in the risk assessment and the control of Japanese encephalitis in non-endemic countries, such as Singapore, that are at risk for JEV transmission.

The lysosome is central to the degradation of proteins, carbohydrates, and lipids and their salvage back to the cytosol for reutilization. Lysosomal transporters for amino acids, sugars, and cholesterol have been identified, and the metabolic fates of these molecules in the cytoplasm have been elucidated. Remarkably, it is not known whether lysosomal salvage exists for glycerophospholipids, the major constituents of cellular membranes. By using a transport assay screen against orphan lysosomal transporters, we identified the major facilitator superfamily protein Spns1 that is ubiquitously expressed in all tissues as a proton-dependent lysophosphatidylcholine (LPC) and lysophosphatidylethanolamine (LPE) transporter, with LPC and LPE being the lysosomal breakdown products of the most abundant eukaryotic phospholipids, phosphatidylcholine and phosphatidylethanolamine, respectively. Spns1 deficiency in cells, zebrafish embryos, and mouse liver resulted in lysosomal accumulation of LPC and LPE species with pathological consequences on lysosomal function. Flux analysis using stable isotope-labeled phospholipid apolipoprotein E nanodiscs targeted to lysosomes showed that LPC was transported out of lysosomes in an Spns1-dependent manner and re-esterified back into the cytoplasmic pools of phosphatidylcholine. Our findings identify a phospholipid salvage pathway from lysosomes to the cytosol that is dependent on Spns1 and critical for maintaining normal lysosomal function.

Based on census data, over one-third of the US population identifies as a racial or ethnic minority. This group of racial and ethnic minorities is more likely to develop cancer and die from it when compared with the general population of the USA. These disparities are most pronounced in the African American community. Despite overall CRC rates decreasing nationally and within certain racial and ethnic minorities in the USA, there continue to be disparities in incidence and mortality when compared with non-Hispanic Whites. The disparities in CRC incidence and mortality are related to systematic racism and bias inherent in healthcare systems and society. Disparities in CRC management will continue to exist until specific interventions are implemented in the context of each racial and ethnic group. This review's primary aim is to highlight the disparities in CRC among African Americans in the USA. For surgeons, understanding these disparities is formative to creating change and improving the quality of care, centering equity for all patients., (© 2021. Society of Surgical Oncology.)

Rodents living alongside humans increases the probability of encounter and also the transmission of rodent-borne diseases. Singapore's cosmopolitan urban landscape provides a perfect setting to study the prevalence of four rodent-borne pathogens: Seoul hantavirus (SEOV), Leptospira species, Rickettsia typhi and Yersinia pestis, and identify the potential risk factors which may influence rodent density and transmission of rodent-borne diseases. A total of 1143 rodents were trapped from 10 unique landscape structures throughout Singapore. Real-time quantitative Polymerase Chain Reactions were used to detect pathogenic and intermediate Leptospira spp. and Yersinia pestis, whereas the seroprevalence of SEOV and R. typhi were analysed by Enzyme-Linked Immunosorbent Assay and Immunofluorescence Assay respectively. Multivariable logistic regression analysis was used to evaluate the association between prevalence of infection in rodent reservoirs and risk factors. Most of the rodents were caught in public residential developments (62.2%). Among the tested rodents, 42.4% were infected with Leptospira spp., while 35.5% and 32.2% were seropositive for SEOV and R. typhi respectively, whereas Yersinia pestis was not detected. Furthermore, risk factors including habitat, species, gender, and weight of rodents, influenced prevalence of infection to a varying extent. This study highlights the presence of Leptospira spp., SEOV and R. typhi in Singapore's rodent population, suggesting the need for effective rodent management and sanitation strategies to prevent further circulation and transmission to humans., (© 2022. The Author(s).)

Background: In the US, opioids are overprescribed after surgery contributing to the opioid epidemic. Patients' expectations regarding postoperative opioids remains unclear., Methods: A representative survey using random-digit dial telephone sampling of English-speaking adults in US was conducted from August 28 to December 11, 2019., Results: Of the 1533 eligible persons contacted, 1000 completed the interviews yielding a cooperation rate of 65%. The mean age was 47 (±18) years, half were men, and most were non-Hispanic white (73%). Forty-eight percent expected an opioid prescription after major surgery, 50% worry about addiction, and 61% believe they contribute to the opioid epidemic. Interestingly, 31% assume that opioid-dependent users were first exposed to opioids following surgery., Conclusion: Many Americans surveyed expect to receive an opioid containing pain medication after major surgery, but fear the risk of addiction and believe that they are contributing to the opioid epidemic. They do not think that opioid-dependent users were first exposed to opioids after surgery. This discordance may represent an area of policy action and education., (Copyright © 2021. Published by Elsevier Inc.)

Significant variations in the patterns of care, incidence, and mortality rates of several common cancers have been noted. These disparities have been attributed to a complex interplay of factors, including genetic, environmental, and healthcare-related components. Within this review, primarily focusing on commonly occurring cancers (breast, lung, colorectal), we initially summarize the burden of these disparities with regard to incidence and screening patterns. We then explore the interaction between several proven genetic, epigenetic, and environmental influences that are known to contribute to these disparities., (© 2021. Society of Surgical Oncology.)

Cellular senescence is a complex and multistep biological process which cells can undergo in response to different stresses. Referring to a highly stable cell cycle arrest, cellular senescence can influence a multitude of biological processes-both physiologically and pathologically. While phenotypically diverse, characteristics of senescence include the expression of the senescence-associated secretory phenotype, cell cycle arrest factors, senescence-associated β-galactosidase, morphogenesis, and chromatin remodelling. Persistent senescence is associated with pathologies such as aging, while transient senescence is associated with beneficial programmes, such as limb patterning. With these implications, senescence-based translational studies, namely senotherapy and pro-senescence therapy, are well underway to find the cure to complicated diseases such as cancer and atherosclerosis. Being a subject of major interest only in the recent decades, much remains to be studied, such as regarding the identification of unique biomarkers of senescent cells. This review attempts to provide a comprehensive understanding of the diverse literature on senescence, and discuss the knowledge we have on senescence thus far.

To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization., (© 2021. Italian Society of Surgery (SIC).)

Background: Success in academic surgery is challenging and research cannot survive without funding. NIH K-awards are designed to mentor junior investigators to achieve independence. As a result we aimed to study K awardees in departments of surgery and learn from their experience., Material and Methods: Utilizing the NIH RePORTer database and filtering by department of surgery, clinically active surgeons receiving a K-award between 2008 and 2018 were asked to complete an online survey. Qualitative data from two open-ended questions were coded independently using standard qualitative methods by three researchers. Using grounded theory, major themes emerged from the codes., Results: Of the 144 academic surgeons identified, 89 (62%) completed the survey. The average age was 39 ± 3 when the K-award was granted. Most identified as white (69%). Men (70%) were more likely to be married (P = 0.02) and have children (P = 0.05). To identify intention to pursue R01 funding, surgeons having a K-award for 5 y or more were analyzed (n = 45). Most either intended to (11%) or had already applied (80%) of which 36% were successful. Men were more likely to apply (P = 0.05). Major themes to succeed include protected time, mentorship, and support from leadership. Common barriers to overcome include balancing time, pressures to be clinically productive, and funding., Conclusions: The demographics and career trajectory of NIH K-awarded surgeons is described. The lack of underrepresented minorities receiving grants is concerning. Most recipients required more than one application attempt and plan to or have applied for R01 funding. The major themes were very similar; a supportive environment and time available for research are the most crucial factors to succeed as an academic surgeon., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction., Methods: Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition., Results: A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups., Discussion: Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.

Background: As an increasing number of general surgery residents apply for fellowship positions, it is important to identify factors associated with successful matriculation. For applicants to colon and rectal surgery, there are currently no objective data available to distinguish which applicant attributes lead to successful matriculation., Objective: The purpose of this study was to identify objective factors that differentiate colon and rectal surgery fellowship applicants who successfully matriculate with those who apply but do not matriculate., Design: This was a retrospective analysis of colon and rectal surgery applicant characteristics., Settings: Deidentified applicant data provided by the Association of American Medical Colleges from 2015 to 2017 were included., Main Outcome Measures: Applicant demographics, medical school and residency factors, number of program applications, number of publications, and journal impact factors were analyzed to determine associations with successful matriculation., Results: Most applicants (n = 371) and subsequent matriculants (n = 248) were white (61%, 62%), male (65%, 63%), US citizens (80%, 88%) who graduated from US allopathic medical schools (66%, 75%). Statistically significant associations included graduation from US allopathic medical schools (p < 0.0001), US citizenship (p < 0.0001), and number of program applications (p = 0.0004). Other factors analyzed included American Osteopathic Association membership (p = 0.57), university-based residency (p = 0.51), and residency association with a colon and rectal surgery training program (p = 0.89). Number of publications and journal impact factors were not statistically different between cohorts (p = 0.067, p = 0.150)., Limitations: American Board of Surgery In-Training Examination scores, rank list, and subjective characteristics, such as strength of interview and letters of recommendation, were not available using our data source., Conclusions: Successful matriculation to a colon and rectal surgery fellowship program was found to be associated with US citizenship, graduation from a US allopathic medical school, and greater number of program applications. The remaining objective metrics analyzed were not associated with successful matriculation. Subjective and objective factors that were unable to be measured by this study are likely to play a determining role. See Video Abstract at http://links.lww.com/DCR/B415., Evaluacin De Factores Vinculados En La Inmatriculacin Exitosa Para Becas De Ciruga Colorrectal: ANTECEDENTES:A medida que un número cada vez mayor de residentes de Cirugía General solicitan una beca, es importante identificar los factores vinculados con una inmatriculación exitosa. Para los candidatos a una beca en Cirugía Colorrectal, hoy en día no existen datos objetivos disponibles para distinguir qué atributos del solicitante conducen a una inmatriculación exitosa.OBJETIVO:Identificar objetivamente los factores que diferencian un candidato a una beca en Cirugía Colorrectal que se inmatricula con éxito de aquel que aplica pero no llega a inmatricularse.DISEÑO:Análisis retrospectivo de las características de los solicitantes de beca para Cirugía Colorrecatl.AJUSTES:Datos de los solicitantes no identificados, proporcionados por la Asociación de Colegios Médicos Estadounidenses de 2015 a 2017.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los factores demográficos del solicitante, las facultades de medicina y los factores de la residencia, el número de solicitudes de programas, el número y el factor de impacto de las publicaciones realizadas para determinar la asociación con una inmatriculación exitosa.RESULTADOS:La mayoría de los solicitantes (n = 371) que posteriormente fueron inmatriculados exitosamente (n = 248) eran blancos (61%, 62%, respectivamente), hombres (65%, 63%), ciudadanos estadounidenses (80%, 88%) que se graduaron de Facultades de medicina alopática en los EE. UU. (66%, 75%). Las asociaciones estadísticamente significativas incluyeron la graduación de las escuelas de medicina alopática de los EE. UU. (P <0,0001), la ciudadanía de los EE. UU. (P <0,0001) y el número de solicitudes de programas (p = 0,0004). Otros factores analizados incluyeron: membresía AOA (p = 0,57), la residencia universitaria (p = 0,51) y asociación de la residencia con un programa de formación en Cirugía Colorrectal (p = 0,89). El número de publicaciones y los factores de impacto de las revistas no fueron estadísticamente diferentes entre las cohortes (p = 0,067, p = 0,15, respectivamente).LIMITACIONES:El Score ABSITE, la posición en lista de clasificación y las características subjetivas como el de una buena entrevista y las cartas de recomendación no se encontraban disponibles en la fuente de datos.CONCLUSIONES:Se encontró que la inmatriculación exitosa a un programa de becas de Cirugía Colorreectal estaba asociada con la ciudadanía estadounidense, la graduación en una Facultad de medicina alopática en los EE. UU, y al mayor número de solicitudes de programas. El analisis de las medidas objetivas restantes no se asociaron con una inmatriculación exitosa. Es probable que los factores subjetivos y objetivos que no pudieron ser medidos por este estudio jueguen un papel determinante. Consulte Video Resumen en http://links.lww.com/DCR/B415. (Traducción-Dr Xavier Delgadillo)., (Copyright © The ASCRS 2020.)

Altered glycosylations, which are associated with expression and activities of glycosyltransferases, can dramatically affect the function of glycoproteins and modify the behavior of tumor cells. ST3GAL1 is a sialyltransferase that adds sialic acid to core 1 glycans, thereby terminating glycan chain extension. In breast carcinomas, overexpression of ST3GAL1 promotes tumorigenesis and correlates with increased tumor grade. In pursuing the role of ST3GAL1 in breast cancer using ST3GAL1 -siRNA to knockdown ST3GAL1 , we identified CD55 to be one of the potential target proteins of ST3GAL1. CD55 is an important complement regulatory protein, preventing cells from complement-mediated cytotoxicity. CD55 had one N -linked glycosylation site in addition to a Ser/Thr-rich domain, which was expected to be heavily O -glycosylated. Detailed analyses of N - and O -linked oligosaccharides of CD55 released from scramble or ST3GAL1 siRNA-treated breast cancer cells by tandem mass spectrometry revealed that the N -glycan profile was not affected by ST3GAL1 silencing. The O -glycan profile of CD55 demonstrated a shift in abundance to nonsialylated core 1 and monosialylated core 2 at the expense of the disialylated core 2 structure after ST3GAL1 silencing. We also demonstrated that O -linked desialylation of CD55 by ST3GAL1 silencing resulted in increased C3 deposition and complement-mediated lysis of breast cancer cells and enhanced sensitivity to antibody-dependent cell-mediated cytotoxicity. These data demonstrated that ST3GAL1-mediated O -linked sialylation of CD55 acts like an immune checkpoint molecule for cancer cells to evade immune attack and that inhibition of ST3GAL1 is a potential strategy to block CD55-mediated immune evasion., (©2020 American Association for Cancer Research.)

Background: Attrition from general surgery residency is high with a national rate of 20%. We evaluated potential associations between financial considerations and attrition., Methods: National prospective cohort study of categorical general surgery trainees., Results: Of the 1048 interns who started training in 2007, 681 (65%) had complete survey and follow-up data. In logistic regression, those with higher starting attending salary expectations (>$300K) were more likely to leave training (OR 2.9, 95% CI 1.2-6.9). Women with a partner who earned more (>$50K/year) were more likely to leave training (OR 4.1, 95% CI 1.6-10.5). In a subgroup of interns undecided about their future practice setting (academic, community, private practice, industry), those with less debt (≤$100K) were more likely to leave training (OR 2.4, 95% CI 1.1-5.2)., Conclusions: Several financial matters were associated with attrition. Addressing these financial concerns may help decrease attrition in surgical training and improve surgical training., Competing Interests: Declaration of competing interest Dr. Yeo’s spouse receives salary from Bioscrip, Inc. a home infusion company. Dr. Sosa is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by Novo Nordisk, GlaxoSmithKline, Astra Zeneca, and Eli Lilly. Drs. Dolan and Symer receive support from an NIH AHRQ T-32HS000066 grant. The authors have no other potential conflicts to disclose., (Copyright © 2020. Published by Elsevier Inc.)

On March 1, 2020, the first case of coronavirus disease 2019 (COVID-19) was confirmed in New York, New York. Since then, the city has emerged as an epicenter for the ongoing pandemic in the US. To meet the anticipated demand caused by the predicted surge of patients with COVID-19, the Department of Surgery at NewYork-Presbyterian Hospital/Weill Cornell Medicine developed and executed an emergent restructuring of general surgery resident teams and educational infrastructure. The restructuring of surgical services described in this Special Communication details the methodology used to safely deploy the necessary amount of the resident workforce to support pandemic efforts while maintaining staffing for emergency surgical care, limiting unnecessary exposure of residents to infection risk, effectively placing residents in critical care units, and maintaining surgical education and board eligibility for the training program as a whole.

Reissner fibre (RF), discovered by the 19 th -century German anatomist Ernst Reissner, is a filamentous structure present in cerebrospinal fluid (CSF). RF forms by aggregation of a glycoprotein called SCO-spondin (Sspo), but its function has remained enigmatic. Recent studies have shown that zebrafish sspo mutants develop a curved embryonic body axis. Zebrafish embryos with impaired cilia motility also develop curved bodies, which arises from failure of expression of urotensin related peptide ( urp ) genes in CSF-contacting neurons (CSF-cNs), impairing downstream signalling in trunk muscles. Here, we show that sspo mutants can survive into adulthood, but display severe curvatures of the vertebral column, resembling the common human spine disorder idiopathic scoliosis (IS). sspo mutants also exhibit significant reduction of urp gene expression from CSF-cNs. Consistent with epinephrine in CSF being bound by RF and required for urp expression, treating sspo mutants with this catecholamine rescued expression of the urp genes and axial defects. More strikingly, providing Urp2, specifically in the CSF-cNs, rescued body curvature of sspo homozygotes during larval stages as well as in the adult. These findings bridge existing gaps in our knowledge between cilia motility, RF, Urp signalling and spine deformities, and suggest that targeting the Urotensin pathway could provide novel therapeutic avenues for IS., Competing Interests: Competing interestsThe authors declare no competing or financial interests., (© 2020. Published by The Company of Biologists Ltd.)

Importance: American Board of Surgery board certification requires passing both a written qualifying examination and an oral certifying examination. No studies have been conducted assessing the effect of sociodemographic variables on board passage rates., Objective: To evaluate if trainee sociodemographic factors are associated with board passage rates., Design, Setting, and Participants: This national and multi-institutional prospective observational cohort study of 1048 categorical general surgery trainees starting in 2007-2008 were surveyed. Data collection began in June 2007, follow-up was completed on December 31, 2016, and analysis began September 2018., Main Outcomes and Measures: Survey responses were linked to American Board of Surgery board passage data., Results: Of 662 examinees who had complete survey and follow-up data, 443 (65%) were men and 459 (69%) were white, with an overall board passage rate of 87% (n = 578). In a multinomial regression model, trainees of Hispanic ethnicity were more likely to not attempt the examinations (vs passed both) than non-Hispanic trainees (odds ratio [OR], 4.7; 95% CI, 1.5-14). Compared with examinees who were married with children during internship, examinees who were married without children (OR, 0.3; 95% CI, 0.1-0.8) or were single (OR, 0.4; 95% CI, 0.2-0.9) were less likely to fail the examinations. Logistic regression showed white examinees compared with nonwhite examinees (black individuals, Asian individuals, and individuals of other races) (OR, 1.8; 95% CI, 1.03-3.0) and examinees who performed better on their first American Board of Surgery In-Training Examination (OR, 1.03; 95% CI, 1.02-1.05) were more likely to pass the qualifying examination on the first try. White examinees compared with nonwhite examinees (OR, 1.8; 95% CI, 1.1-2.8), non-Hispanic compared with Hispanic examinees (OR, 2.4; 95% CI, 1.2-4.7), and single women compared with women who were married with children during internship (OR, 10.3; 95% CI, 2.1-51) were more likely to pass the certifying examination on the first try., Conclusions and Relevance: Resident race, ethnicity, sex, and family status at internship were observed to be associated with board passage rates. There are multiple possible explanations for these worrisome observations that need to be explored. Tracking demographics of trainees to help understand passage rates based on demographics will be important. The American Board of Surgery already has begun addressing the potential for unconscious bias among board examiners by increasing diversity and adding implicit bias training.

Background: Weight loss surgery is safe and effective, but fluid and electrolyte balance remains problematic postoperatively. We developed a mobile app to help patients recover after weight loss surgery., Material and Methods: Single-center prospective, mixed-methods, participatory research design study of eligible English-speaking adults undergoing weight loss surgery was used. Patients used the app for 30 d after surgery. We developed and refined the app from July 2017 to October 2018. The principal component of the app is a daily survey designed to assess patients' recovery. The app was revised based on patient feedback, and we compared app utilization between initial and updated versions of the app. Primary outcome was successful patient engagement, which we defined as 80% of patients completing at least 70% of the surveys., Results: Ten patients completed the trial period, four with the initial version of the app, and six with the updated version. All patients expressed satisfaction with the app and most frequently reported that push notifications were helpful. We found that one (25%) patient completed at least 70% of the surveys in the initial version of the app. In the updated version, five (83.3%) of patients completed at least 70% of the surveys, passing our criteria for successful engagement., Conclusions: Participatory research design in app development requires continuous evaluation and refinement to patient and clinician needs. This effort is essential as we observed significant improvement in app utilization. Our next step is to pilot the app in a larger set of patients to assess utility and feasibility., (Copyright © 2019 Elsevier Inc. All rights reserved.)

When choosing a career as a surgeon, we knowingly dedicate ourselves to a lifetime of service and education. Our commitment as physicians is but one of many commitments in the larger scheme of life where we function as family members, friends, athletes, and numerous other roles. Work and life are often described as two separate entities diametrically opposed to each other. In reality, personal and professional goals are part of a continuum where work is a major part of our lives and who we are as people and is not necessarily separate from the others. The goal-directed nature with which we approach our responsibilities as surgeons should be applied to all domains of life. As we progress along the training paradigm from intern to attending, control over time allocation increases. Understanding oneself, determining priorities, applying realistic expectations, cultivating a supportive environment, setting personal and professional goals, and being held accountable for progress and completion of these goals will allow us to utilize limited time efficiently to achieve what we individually desire from life., (© Thieme Medical Publishers.)

Background: Robotic surgery for colorectal cancer offers many potential benefits, but as with any new technology, there is a learning curve., Objective: We sought to identify trends in the uptake of robotic resection and associated complication rates., Design: This was a case sequence analysis of robotic surgery for colorectal cancer., Settings: The study was conducted using the New York Statewide Planning and Research Cooperation System database., Patients: Adults undergoing colorectal resection for cancer from 2008 through 2016 were identified in the New York Statewide Planning and Research Cooperative database. Case sequence analysis was used to describe surgeon experience, with cases grouped into quartiles based on the chronological order in which each surgeon performed them., Main Outcome Measures: Outcomes included in-hospital major events (myocardial infarction, pulmonary embolism, shock, and death) and iatrogenic complications. Generalized linear mixed models were used to estimate the relationship between case sequence and operative outcomes., Results: A total of 2763 robotic procedures were included, with volume increasing from 76 cases in 2010 to 702 cases in 2015. The proportion of cases performed by surgeons earliest in their learning curve has increased to 18.2% in 2015. This quartile was composed of more black patients (11.4% earliest quartile vs 7.0% latest quartile; p < 0.001) and rectal resections (50.1% earliest quartile vs 38.9% latest quartile; p < 0.001). In adjusted analysis, major complications did not improve with increasing case sequence. However, with increasing cumulative surgeon case sequence iatrogenic complications were reduced, particularly in the highest volume quartile (OR = 0.29 (95% CI, 0.09-0.88); p = 0.03). Odds of prolonged length of stay (>75 percentile) were also decreased (OR = 0.50 (95% CI, 0.37-0.69); p < 0.001)., Limitations: Data were derived from an administrative database., Conclusions: Robotic colorectal resection has been rapidly adopted. Surgeons earliest in their experience have increased iatrogenic complications and continue to make up a large proportion of cases performed. See Video Abstract at http://links.lww.com/DCR/A974. ANÁLISIS DE SECUENCIA DE CASOS DE LA CURVA DE APRENDIZAJE DE RESECCIÓN ROBÓTICA COLORRECTAL: La cirugía robótica para el cáncer colorrectal ofrece muchos beneficios potenciales, pero como con cualquier nueva tecnología, presenta una importante curva de aprendizaje., Objetivo: Se buscó identificar tendencias en la aceptación de la resección robótica y las tasas de complicaciones asociadas. DISEÑO:: Análisis de secuencia de casos de cirugía robótica para cáncer colorrectal AJUSTES:: Base de datos del Sistema de Cooperación para la Investigación y la Planificación del Estado de Nueva York., Pacientes: Los adultos que se sometieron a una resección colorrectal en caso de cáncer desde 2008 hasta 2016 se identificaron en la base de datos de la Cooperativa de Investigación y Planificación del Estado de Nueva York. Se utilizó un análisis de secuencia de casos para describir la experiencia del cirujano, y los casos se agruparon en cuartiles según el orden cronológico en el que cada cirujano los operó., Resultados Principales: Los resultados incluyeron los eventos intrahospitalarios mayores (infarto de miocardio, embolia pulmonar, shock y muerte) y las complicaciones iatrogénicas. Se utilizaron modelos lineales generalizados mixtos para estimar la relación entre la secuencia de casos y los resultados operativos., Resultados: Se incluyeron un total de 2.763 procedimientos robóticos, con un aumento del volumen de 76 casos en 2010 a 702 casos en 2015. La proporción de casos realizados por cirujanos en su primera curva de aprendizaje aumentó a 18.2% en 2015. Este cuartil estaba compuesto por una mayoría de pacientes de color (11.4% en el cuartil más temprano versus 7.0% en el último cuartil, p < 0.001) y de resecciones rectales (50.1% en el primer cuartil vs 38.9% en el último cuartil, p < 0.001). En el ajuste del análisis, las complicaciones mayores no mejoraron al aumentar la secuencia de casos. Sin embargo, al aumentar la secuencia acumulada de casos de cirujanos, se redujeron las complicaciones iatrogénicas, particularmente en el cuartil de mayor volumen (OR = 0,29; IC del 95%: 0,09 a 0,88; p = 0,03). Las probabilidades de una estadía hospitalaria prolongada (> percentil 75) también disminuyeron (OR 0,50; IC del 95%: 0,37 a 0,69; p < 0,001)., Limitaciones: Los valores fueron derivados desde una base de datos administrativa., Conclusiones: La resección colorrectal robótica ha sido adoptada rápidamente. Los cirujanos durante su experiencia inicial han presentado un elevado número de complicaciones iatrogénicas y éstas representan todavía, una gran proporción de casos realizados. Vea el Resumen del Video en http://links.lww.com/DCR/A974.

ST3Gal1 is a key sialyltransferase which adds α2,3-linked sialic acid to substrates and generates core 1 O-glycan structure. Upregulation of ST3Gal1 has been associated with worse prognosis of breast cancer patients. However, the protein substrates of ST3Gal1 implicated in tumor progression remain elusive. In our study, we demonstrated that ST3GAL1-silencing significantly reduced tumor growth along with a notable decrease in vascularity of MCF7 xenograft tumors. We identified vasorin (VASN) which was shown to bind TGF-β1, as a potential candidate that links ST3Gal1 to angiogenesis. LC-MS/MS analysis of VASN secreted from MCF7, revealed that more than 80% of its O-glycans are sialyl-3T and disialyl-T. ST3GAL1-silencing or desialylation of VASN by neuraminidase enhanced its binding to TGF-β1 by 2- to 3-fold and thereby dampening TGF-β1 signaling and angiogenesis, as indicated by impaired tube formation of HUVECs, suppressed angiogenesis gene expression and reduced activation of Smad2 and Smad3 in HUVEC cells. Examination of 114 fresh primary breast cancer and their adjacent normal tissues showed that the expression levels of ST3Gal1 and TGFB1 were high in tumor part and the expression of two genes was positively correlated. Kaplan Meier survival analysis showed a significantly shorter relapse-free survival for those with lower expression VASN, notably, the combination of low VASN with high ST3GAL1 yielded even higher risk of recurrence (p = 0.025, HR = 2.967, 95% CI = 1.14-7.67). Since TGF-β1 is known to transcriptionally activate ST3Gal1, our findings illustrated a feedback regulatory loop in which TGF-β1 upregulates ST3Gal1 to circumvent the negative impact of VASN., (© 2018 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

FUT1 and FUT2 encode alpha 1, 2-fucosyltransferases which catalyze the addition of alpha 1, 2-linked fucose to glycans. Glycan products of FUT1 and FUT2, such as Globo H and Lewis Y, are highly expressed on malignant tissues, including breast cancer. Herein, we investigated the roles of FUT1 and FUT2 in breast cancer. Silencing of FUT1 or FUT2 by shRNAs inhibited cell proliferation in vitro and tumorigenicity in mice. This was associated with diminished properties of cancer stem cell (CSC), including mammosphere formation and CSC marker both in vitro and in xenografts. Silencing of FUT2, but not FUT1, significantly changed the cuboidal morphology to dense clusters of small and round cells with reduced adhesion to polystyrene and extracellular matrix, including laminin, fibronectin and collagen. Silencing of FUT1 or FUT2 suppressed cell migration in wound healing assay, whereas FUT1 and FUT2 overexpression increased cell migration and invasion in vitro and metastasis of breast cancer in vivo. A decrease in mesenchymal like markers such as fibronectin, vimentin, and twist, along with increased epithelial like marker, E-cadherin, was observed upon FUT1/2 knockdown, while the opposite was noted by overexpression of FUT1 or FUT2. As expected, FUT1 or FUT2 knockdown reduced Globo H, whereas FUT1 or FUT2 overexpression showed contrary effects. Exogenous addition of Globo H-ceramide reversed the suppression of cell migration by FUT1 knockdown but not the inhibition of cell adhesion by FUT2 silencing, suggesting that at least part of the effects of FUT1/2 knockdown were mediated by Globo H. Our results imply that FUT1 and FUT2 play important roles in regulating growth, adhesion, migration and CSC properties of breast cancer, and may serve as therapeutic targets for breast cancer., Competing Interests: The authors declare that they have no conflict of interest.

Objective: To describe public willingness to participate in regionalized surgical care for cancer., Summary of Background Data: Improved outcomes at high-volume centers following complex surgery have driven a push to regionalize surgical care. Patient attitudes toward regionalization are not well described., Methods: As part of the Cornell National Social Survey, a cross-sectional telephone survey was performed. Participants were asked about their willingness to seek regionalized care in a hypothetical scenario requiring surgery. Their responses were compared with demographic characteristics. A geospatial analysis of hospital proximity was performed, as well as a qualitative analysis of barriers to regionalization., Results: Cooperation rate was 48.1% with 1000 total respondents. They were an average of 50 years old (range 18 to 100 years) and 48.9% female. About 49.6% were unwilling to travel 5 hours or more to seek regionalized care for improved survival. Age >70 years [odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.19-0.60] and perceived distance to a center >30 minutes (OR 0.60, 95% CI 0.41-0.86) were associated with decreased willingness to seek regionalized care, while high income (OR 2.09, 95% CI 1.39-3.16) was associated with increased willingness. Proximity to a major center was not associated with willingness to travel (OR 0.92, 95% CI 0.67-1.22). Major perceived barriers to regionalization were transportation, life disruption, social support, socioeconomic resources, poor health, and remoteness., Conclusion: Americans are divided on whether the potential for improved survival with regionalization is worth the additional travel effort. Older age and lower income are associated with reduced willingness to seek regionalized care. Multiple barriers to regionalization exist, including a lack of knowledge of the location major centers.

Background: Medical school experience informs the decision to pursue graduate surgical education. However, it is possible that inadequate preparation in medical school is responsible for the high rate of attrition seen in general surgery residency., Materials and Methods: We performed a national prospective cohort study of all categorical general surgery interns who entered training in the 2007-2008 academic year. Interns answered questions about their medical school experience and reasons for pursuing general surgery residency. Responses were linked with American Board of Surgery residency completion data. Multivariable logistic regression was used to evaluate the association between medical school experiences and residency attrition., Results: Seven hundred and ninety-two surgery interns participated, and the overall attrition rate was 19.3%. Most interns had performed ≤8 wk of third year surgery clerkships (53.2% of those who completed versus 49.7% of those who dropped out, P = 0.08). After multivariable adjustment, shorter duration of third year rotations was protective from attrition (OR: 0.53, 95% CI: 0.29-0.99; P = 0.05). There was no difference in attrition based on whether a surgical subinternship was performed (OR: 0.67, 95% CI: 0.38-1.19; P = 0.18). Residents who perceived that their medical school surgical faculty were happy with their careers were less likely to experience attrition (OR: 0.57, 95% CI: 0.34-0.96; P = 0.03), but those who had gotten along well with attending surgeons had higher odds of attrition (OR: 2.93, 95% CI: 1.34-6.39, P < 0.01)., Conclusions: Increased quality, rather than quantity, of clerkships is associated with improved rates of residency completion. Learner relationships with positive yet demanding role models were associated with a reduced risk of attrition., (Copyright © 2018. Published by Elsevier Inc.)

Background: Immobility and prolonged bed rest often lead to heel pressure ulcers in patients. A point prevalence audit undertaken in the orthopaedic wards of a Singapore tertiary hospital reported that 6 out of 30 patients who were audited had mild to blanching redness on their heels., Aims: The evidence-based project sought to achieve 80% compliance from nurses to perform heel off-loading practice and a 50% reduction in the occurrence of heel pressure ulcers., Methods: The project, lasting two years, was undertaken in two orthopaedic wards and utilized a pre- and post-implementation audit strategy using the Joanna Briggs Institute on-line 'Practical Application of Clinical Evidence System' and 'Getting Research into Practice' programs. Implementation occurred in four phases and involved a sample consisting of 30 adult patients., Results: Nurses' compliance with performing heel off-loading techniques increased. The post-implementation audit showed 93.3% compliance of nurses undertaking heel off-loading techniques in the subsequent four follow-up audits. Meanwhile, the compliance with documentation increased from 63.3% to 86.7%. The project resulted in more than 50% reduction in stage one heel pressure ulcers., Conclusion: The implementation of heel off-loading techniques significantly reduced the incidences of heel pressure ulcers in orthopaedic wards., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

GFRA1 and RET are overexpressed in estrogen receptor (ER)-positive breast cancers. Binding of GDNF to GFRA1 triggers RET signaling leading to ER phosphorylation and estrogen-independent transcriptional activation of ER-dependent genes. Both GFRA1 and RET are membrane proteins which are N-glycosylated but no O-linked sialylation site on GFRA1 or RET has been reported. We found GFRA1 to be a substrate of ST3GAL1-mediated O-linked sialylation, which is crucial to GDNF-induced signaling in ER-positive breast cancer cells. Silencing ST3GAL1 in breast cancer cells reduced GDNF-induced phosphorylation of RET, AKT and ERα, as well as GDNF-mediated cell proliferation. Moreover, GDNF induced transcription of ST3GAL1, revealing a positive feedback loop regulating ST3GAL1 and GDNF/GFRA1/RET signaling in breast cancers. Finally, we demonstrated ST3GAL1 knockdown augments anti-cancer efficacy of inhibitors of RET and/or ER. Moreover, high expression of ST3GAL1 was associated with poor clinical outcome in patients with late stage breast cancer and high expression of both ST3GAL1 and GFRA1 adversely impacted outcome in those with high grade tumors., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Vascular endothelial growth factor (VEGF) has been shown to induce neurogenesis in the brain and yield neuroprotective effects. It is hypothesized that chemotherapy reduces circulating VEGF levels and leads to cognitive decline among patients. This multicenter longitudinal study aimed to evaluate the impact of chemotherapy on VEGF levels and the association between VEGF levels and cognitive function., Patients and Methods: A total of 145 early-stage breast cancer patients were recruited and assessed before chemotherapy (T1), during chemotherapy (T2), and at the end of chemotherapy (T3). At each time point, plasma VEGF levels were assessed using a multiplex immunoassay. Cognitive function was assessed using both Functional Assessment of Cancer Therapy-Cognitive Function, Version 3 (FACT-Cog), and Headminder (a computerized, web-based neuropsychologic battery)., Results: Generally, we observed higher-than-baseline plasma VEGF levels after the start of chemotherapy (P < .001). Among patients receiving anthracycline-based chemotherapy, the median plasma VEGF levels were significantly higher at T2 (T2: 37.3 pg/mL vs. T1: 21.3 pg/mL; P < .001) and T3 (T3: 35.5 pg/mL vs. T1: 21.3 pg/mL; P < .001) than at baseline. Plasma VEGF levels were not associated with chemotherapy-associated cognitive impairment., Conclusion: Breast cancer patients experience an increasing trend in plasma VEGF levels during chemotherapy, and the regimen types may have a differential effect on circulating VEGF levels. Furthermore, changes in plasma VEGF levels during chemotherapy were not associated with cognitive impairment. VEGF may play a minor role in mediating the occurrence of chemotherapy-associated cognitive impairment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Racial/ethnic diversity remains poor in academic surgery. However, no study has quantified differences in the rates of retention and promotion of underrepresented minority (URM) academic surgeons., Methods: The American Association of Medical Colleges Faculty Roster was used to track all first-time assistant and associate professors appointed between 1/1/2003 and 12/31/2006. Primary endpoints were percent promotion and retention at ten-year follow-up., Results: Initially, the majority of assistant and associate professors of surgery were White (62%; 75%). Black assistant professors had lower 10-year promotion rates across all specialties (p < 0.01). There were no race/ethnicity-based differences in promotion for associate professors. Retention rates were higher for White assistant professors than Asian or Black/Hispanic/Other minority faculty (61.3% vs 52.8% vs. 50.8% respectively; p < 0.01). There was no difference in 10-year retention rates among associate professors based on race/ethnicity., Conclusions: Underrepresented minority surgeons are less likely to remain in academia and Black assistant professors have the lowest rates of promotion. These findings highlight the need to develop institutional programs to better support and develop minority faculty members in academic medicine., (Copyright © 2018. Published by Elsevier Inc.)

Anal cancer is a rare condition, although its incidence has been increasing over the past several decades, particularly in women. The majority of anal cancers are squamous cell cancers and are linked with human papilloma virus (HPV) infection. Recent work in HPV basic science has delineated the mechanism by which the virus leads to the development of anal cancer. With widespread availability of an HPV vaccine since 2006, vaccination has become an important strategy for anal cancer prevention. However, in the US, there remain no guidelines for anal cancer screening. Treatment of anal cancer is dictated largely by accurate staging, which is generally accomplished with a combination of physical exam, magnetic resonance imaging, computed tomography, and positron emission tomography. Chemoradiation remains the mainstay of treatment for most patients, with surgery reserved for salvage therapy. Recent trials have identified the optimal use of available chemotherapeutics. Exciting developments in immune therapies targeting HPV oncoproteins as well as therapeutic vaccines may soon dramatically change the way patients with anal cancer are managed., Competing Interests: Competing interests: Heather L. Yeo’s spouse receives salary from Bioscrip, Inc., a home infusion company. The authors have no other potential competing interests to disclose.No competing interests were disclosed.No competing interests were disclosed.No competing interests were disclosed.

Background: There is no consensus on the ideal management of complicated appendicitis., Methods: The New York State Planning and Research Cooperative database was used to identify all patients admitted with complicated appendicitis and undergoing appendectomy within 1-year. Primary outcome was any complication. Secondary outcomes included length of stay (LOS), hospital charges, and laparoscopy use. Outcomes were compared in appendectomy before or after 48h from admission., Results: 31,167 patients ≥18yo were identified for analysis, 28,015(89.9%) underwent early appendectomy. Early appendectomy patients were more likely to be White (69.8% vs. 64.2% p < 0.01), and commercially insured (53.1% vs. 45.4%, p < 0.01). Of the 3152 undergoing delayed surgery, 1610(51.1%) had surgery later during the index admission, 715(22.7%) were readmitted urgently and underwent appendectomy, and 827(26.2%) had elective appendectomy. Patients undergoing delayed surgery had more complications (OR 1.34 95%CI 1.23-1.45), readmissions (OR 1.55 95%CI 1.42-1.70), high hospital charges (OR 4.79 95%CI 4.35-5.27), and prolonged LOS (OR 6.12 95%CI 5.61-6.68)., Conclusions: In this population-level study of complicated appendicitis we found more complications, longer LOS, and higher charges in patients undergoing delayed surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Importance: Attrition from general surgery training is highest during internship. Whether the expectations and attitudes of new trainees affect their subsequent risk of attrition is unknown., Objective: To identify the expectations of general surgery residency associated with attrition from training., Design, Setting, and Participants: This prospective observational cohort study included categorical general surgery interns entering training in the 2007-2008 academic year. Residents were surveyed regarding their expectations of training and of life as an attending at the start of their intern year (June 1 to August 31, 2007). Expectations were grouped into factors by principal component analysis, and a multivariable model was created using these factors in addition to known demographic and program characteristics associated with attrition. Follow-up was completed on December 31, 2016., Main Outcomes and Measures: Attrition from training was determined by linkage to American Board of Surgery resident files through 2016, allowing 8 additional years of follow-up., Results: Of 1048 categorical surgery interns in the study period, 870 took the survey (83.0% response rate), and 828 had complete information available for analysis (524 men [63.3%], 303 women [36.6%], and 1 missing information [0.1%]). Most were white (569 [69.1%]) and at academic programs (500 [60.4%]). Six hundred sixty-six residents (80.4%) completed training. Principal component analysis generated 6 factors. On adjusted analysis, 2 factors were associated with attrition. Interns who choose their residency based on program reputation (factor 2) were more likely to drop out (odds ratio, 1.08; 95% CI, 1.01-1.15). Interns who expected as an attending to work more than 80 hours per week, to have a stressful life, and to be the subject of malpractice litigation (career life expectation [factor 6]) were less likely to drop out (odds ratio, 0.90; 95% CI, 0.82-0.98)., Conclusions and Relevance: Interns with realistic expectations of the demands of residency and life as an attending may be more likely to complete training. Medical students and residents entering training should be given clear guidance in what to expect as a surgery resident.

Background: The American Board of Surgery In-Training Exam is administered annually to general surgery residents and could provide a way to predict attrition, potentially offering a point of intervention., Methods: In 2007, a national survey of categorical general surgery interns was performed. Resident characteristics were linked to an American Board of Surgery database of American Board of Surgery In-Training Exam scores. Attrition was determined based on completion of training during eight years of follow-up. To identify residents at risk of attrition, American Board of Surgery In-Training Exam scores were analyzed based on average rank and change in American Board of Surgery In-Training Exam score., Results: Of 1,048 residents, 739 (70.5%) participated and 108 (14.6%) did not complete training. Average American Board of Surgery In-Training Exam rank was higher for participants who completed training than those who did not (51.8 vs. 42.7 percentile respectively, P < .001). Ranking below the 25th percentile was less common among those who dropped out (41.7% ranked below 25th percentile and dropped out versus 51.5% ranked below 25th percentile and completed, P = .06), but those whose rank dropped >16.5 percentile points were more likely to leave training (attrition rate 13.0% with a drop versus 6.0% without a drop, P = .003). In adjusted analysis, a one percentile increase in American Board of Surgery In-Training Exam rank was associated with decreased odds of attrition (OR 0.98, P < .01)., Conclusion: Lower American Board of Surgery In-Training Exam scores are associated with attrition, but this difference is small, and some residents complete training with very low scores. A large drop in American Board of Surgery In-Training Exam scores from one year to the next appears to be associated with attrition. Program directors should focus their efforts on these at-risk residents., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Complicated appendicitis is common in children, yet the timing of surgical management remains controversial. Some support initial antibiotics with delayed operation whereas others support immediate operation. While a few randomized trials have evaluated this question, they have been small, single-center trials with limited follow-up. We present a database analysis of outcomes in early versus late surgical management of complicated appendicitis with one-year follow-up., Methods: We conducted a retrospective review of children with complicated appendicitis presenting between 2000 and 2013, utilizing a New York State database. We compare children undergoing later versus early appendectomy with a primary outcome measure of any complication within one year as determined from ICD-9 codes., Results: 8840 children were included in the analysis, 7708 of whom underwent early appendectomy. Patients with late appendectomy were significantly more likely to have at least one complication when compared to those undergoing early appendectomy (34.6% vs 26.7%, p<0.01)., Conclusions: We present the first population-level study evaluating early versus late appendectomy in children with complicated appendicitis with a one-year follow-up period. Children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data corroborated previous studies supporting early operative management., Level of Evidence: This study provides level III evidence of a treatment study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Hormone replacement therapy has been shown to reduce colorectal cancer incidence, but its effect on colorectal cancer mortality is controversial. The objective of this study was to determine the effect of hormone replacement therapy on survival from colorectal cancer., Patients and Methods: We performed a secondary analysis of data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, a large multicenter randomized trial run from 1993 to 2001, with follow-up data recently becoming mature. Participants were women aged 55 to 74 years, without recent colonoscopy. Data from the trial were analyzed to evaluate colorectal cancer incidence, disease-specific mortality, and all-cause mortality based on subjects' use of hormone replacement therapy at the time of randomization: never, current, or former users., Results: A total of 75,587 women with 912 (1.21%) incident colorectal cancers and 239 associated deaths were analyzed, with median follow-up of 11.9 years. Overall, 88.6% were non-Hispanic white, and < 10% had not completed high school. The never-user group was slightly older than the current or former user groups (average, 63.8 vs. 61.4 vs. 63.3 years; P < .001). Almost one-half (47.1%) of the current users had undergone hysterectomy, compared with 21.6% of never-users and 34.0% of former users (P < .001). Adjusted colorectal cancer incidence in current users compared to never-users was lower (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.69-0.94; P = .005), as was death from colorectal cancer (HR, 0.63; 95% CI, 0.47-0.85; P = .002) and all-cause mortality (HR, 0.76; 95% CI, 0.72-0.80; P < .001)., Conclusions: Hormone replacement therapy is associated with a reduced risk of colorectal cancer incidence and improved colorectal cancer-specific survival, as well as all-cause mortality., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Distress is common among cancer and surgical patients and can lead to worse outcomes if untreated. The objective of this study was to explore sources of distress among colorectal cancer patients undergoing surgery., Materials and Methods: This was a qualitative study using in-depth, semistructured, one-on-one interviews in an academic setting. Patients were recruited if they had a pathologically confirmed diagnosis of colon or rectal cancer. Purposive sampling was used to recruit patients who were about to undergo (preoperative), or had recently undergone (postoperative), curative resection for colorectal cancer., Results: All participants (n = 24) reported experiencing distress during treatment. Participants identified sources of distress preoperatively (negative emotional reaction to diagnosis, distress from preconception of cancer diagnosis, and distress interacting with healthcare system). Sources of distress during in-hospital recovery included negative emotional reaction to having a surgery and negative emotions experienced in the hospital. Postoperative sources of distress included mismatch of expectations and experience of recovery, dealing with distressing physical symptoms and complications after surgery, and distress worrying about recurrence. Participants identified other sources of distress that were not time-specific (distress related to social support network, from disruption of life, and worrying about death)., Conclusions: Our results highlight a potential role for a comprehensive screening program to identify which patients require assistance with addressing sources of distress during the surgical experience. Understanding how sources of distress may vary by time will help us tailor interventions at different time points of the surgical experience., (Copyright © 2018 Elsevier Inc. All rights reserved.)