Surgeon's Practice Research Articles

Standardized Fixation Zones and Cone Assessments for Revision Total Knee Arthroplasty Using Deep Learning

BackgroundAchieving adequate implant fixation is critical to optimize survivorship and postoperative outcomes after revision total knee arthroplasty (rTKA). Three anatomical zones (ie, epiphysis, metaphysis, and diaphysis) have been proposed to assess fixation, but are not well-defined. The purpose of the study was to develop a deep learning workflow capable of automatically delineating rTKA zones and cone placements in a standardized way on postoperative radiographs. MethodsA total of 235 patients who underwent rTKA were randomly partitioned (6:2:2 training, validation, and testing split), and a U-Net segmentation workflow was developed to delineate rTKA fixation zones and assess revision cone placement on anteroposterior radiographs. Algorithm performance for zone delineation and cone placement were compared against ground truths from a fellowship-trained arthroplasty surgeon using the dice segmentation coefficient and accuracy metrics. ResultsOn the testing cohort, the algorithm defined zones in 98% of images (8 seconds/image) using anatomical landmarks. The dice segmentation coefficient between the model and surgeon was 0.89 ± 0.08 (interquartile range [IQR]:0.88-0.94) for femoral zones, 0.91 ± 0.08 (IQR: 0.91-0.95) for tibial zones, and 0.90 ± 0.05 (IQR:0.88-0.94) for all zones. Cone identification and zonal cone placement accuracy were 98% and 96%, respectively, for the femur and 96% and 89%, respectively, for the tibia. ConclusionA deep learning algorithm was developed to automatically delineate revision zones and cone placements on postoperative rTKA radiographs in an objective, standardized manner. The performance of the algorithm was validated against a trained surgeon, suggesting that the algorithm demonstrated excellent predictive capabilities in accordance with relevant anatomical landmarks used by arthroplasty surgeons in practice.

ANew Concept for Surgery in European Hospitals? Records of Practice in Germany, Italy, and Spain During the Sixteenth and Early Seventeenth Centuries.

The recent discovery of amanuscript has allowed historians to understand the medical routine in ahospital known as the Schneidhaus in Augsburg between the sixteenth and nineteenth century. The context of the manuscript shows that at this institution, non-academic specialists, generally members of the guild of barber-surgeons and barbers, routinely performed surgical cures of intestinal hernia, scrotal swellings, and vesical calculus. The Schneidhaus exclusively admitted patients applying for such specialised treatments and offered no other services. Such adegree of specialisation within medical establishments seems to have only existed in the Holy Roman Empire at this institution founded by the Fugger family in Augsburg. We propose that the Schneidhaus was either itself amodel hospital or adopted amodel from another site in Europe. In this paper, we investigate the connections of the Schneidhaus to the practice of surgeons in both Italy and Spain. In Italy, amomentous new technique for identifying and removing vesical calculi was first published in 1522. Although surgical treatment was established in Italian hospitals, they tended not to specialise in such surgical treatment exclusively. Moreover, at the time of the hospital's foundation, the Fugger shifted their economic and social focus from Venice to the Iberian Peninsula. In Spain, research in the history of medicine is complicated by outdated notions about specialised surgery, not unlike those that were recently still current regarding the Holy Roman Empire. We attempt to disprove these notions and use the exemplary textbook of one academic physician, Francisco Díaz, to approach specialized surgical practice in sixteenth-century Spain. In his work, Díaz describes the new Italian surgical method in detail and recognizes the importance of craftsman surgeons to both its development and application. However, he also argues for an expanded role for academic physicians as supervisors of craftsman surgeons' work. All this is suggestive of agreater network of surgical professionals within which both the methods of the craft and its organisational structures were transported. As such, the Schneidhaus can be seen as anode that embodied the institutionalization of surgical practice as aEuropean phenomenon. Further research is necessary, and we propose how this might be carried out to reveal these historical phenomena in their full complexity.

Body mass index and benign breast surgeries: A survey of plastic surgeons’ knowledge and attitudes

BackgroundThe academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients. MethodsAn online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022. ResultsThere were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher. ConclusionsRespondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences.

Mechanical Characterization of Human Fascia Lata: Uniaxial Tensile Tests from Fresh-Frozen Cadaver Samples and Constitutive Modelling

Human Fascia Lata (FL) is a connective tissue with a multilayered organization also known as aponeurotic fascia. FL biomechanics is influenced by its composite structure formed by fibrous layers (usually two) separated by loose connective tissue. In each layer, most of the collagen fibers run parallel in a distinct direction (with an interlayer angle that usually ranges from 75-80°), mirroring the fascia's ability to adapt and withstand specific tensile loads. Although FL is a key structure in several musculoskeletal dysfunctions and in tissue engineering, literature still lacks the evidence that proves tissue anisotropy according to predominant collagen fiber directions. For this purpose, this work aims to analyze the biomechanical properties of ex-vivo FL (collected from fresh-frozen human donors) by performing uniaxial tensile tests in order to highlight any differences with respect to loading directions. The experimental outcomes showed a strong anisotropic behavior in accordance with principal collagen fibers directions, which characterize the composite structure. These findings have been implemented to propose a first constitutive model able to mimic the intra- and interlayer interactions. Both approaches could potentially support surgeons in daily practices (such as graft preparation and placement), engineers during in silico simulation, and physiotherapists during musculoskeletal rehabilitation, to customize a medical intervention based on each specific patient and clinical condition.

Frailty Assessment and Prehabilitation as Part of a PeRioperative Evaluation and Planning (PREP) Program for Patients Undergoing Colorectal Surgery.

Frailty assessment and prehabilitation can be incrementally implemented in a multidisciplinary, multiphase pathway to improve patient care. To start, modifications can be made to a surgeon's practice with existing resources while adapting standard pathways for frail patients. Frailty screening can identify patients in need of additional assessment and optimization. Personalized utilization of frailty data for optimization through prehabilitation can improve postoperative outcomes and identify patients who would benefit from adapted care. Additional utilization of the multidisciplinary team can lead to improved outcomes and a strong business case to add additional members of the team.

Reconstructive vascular surgery in pediatric oncology: literature review

Background. In some rare cases pediatric solid tumors may infiltrate or incase major vessels, which may require vascular plastics as part of radical tumor resection. As these situations are rare in pediatric surgeon practice, there is no common approach to this problem. In order to analyze the available experience we reviewed published cases concerning vascular plastics in pediatric oncosurgery. Materials and methods. The references from MEDLINE (PubMed), HighWire Press, and eLibrary electronic databases were analyzed for references describing practical vascular surgery experience with vascular implants published in 2002–2022. Results. There is few published data on major vessels reconstruction in patients with pediatric solid tumors. Most publications describe single cases or small case series. The vascular plastics in these children is difficult due to small vessel diameter, difficulties in choosing the right graft, risk of thrombosis, and the need to provide adequate circulation in a rapidly growing child. As there are no major studies of this subject we still have no consensus on optimal vascular reconstruction tactics in children with solid tumors. Therefore, new systematic studies are needed. Conclusion. We provide a brief review on currently used methods of vascular plastics and reconstruction available for use in children with solid tumors.

CHOOSING WISELY: THE LACK OF VALIDITY OF ULTRASOUND SCANS IN THE INVESTIGATION OF SHOULDER INSTABILITY

We test the clinical validity and financial implications of the proposed Choosing Wisely statement: “Using ultrasound as a screening test for shoulder instability is inappropriate in people under 30 years of age, unless there is clinical suspicion of a rotator cuff tear.”A retrospective chart review from a specialist shoulder surgeon's practice over a two-year period recorded 124 patients under the age of 30 referred with shoulder instability. Of these, forty-one had already had ultrasound scans performed prior to specialist review. The scan results and patient files were reviewed to determine the reported findings on the scans and whether these findings were clinically relevant to diagnosis and decision-making. Comparison was made with subsequent MRI scan results. The data, obtained from the Accident Compensation Corporation (ACC), recorded the number of cases and costs incurred for ultrasound scans of the shoulder in patients under 30 years old over a 10-year period.There were no cases where the ultrasound scan was considered useful in decision-making. No patient had a full thickness rotator cuff tear. Thirty-nine of the 41 patients subsequently had MRI scans. The cost to the ACC for funding ultrasound scans in patients under 30 has increased over the last decade and exceeded one million dollars in the 2020/2021 financial year. In addition, patients pay a surcharge for this test.The proposed Choosing Wisely statement is valid. This evidence supports that ultrasound is an unnecessary investigation for patients with shoulder instability unless there is clinical suspicion of a rotator cuff tear. Ultrasound also incurs costs to the insurer (ACC) and the patient. We recommend x-rays and, if further imaging is indicated, High Tech Imaging with MRI and sometimes CT scans in these patients

Коморбидность синдрома повышенной эпителиальной проницаемости

Syndrome of increased epithelial permeability is one of the most studied pathogenic syndromes in the 21st century. In the English literature, the term “the leaky gut syndrome” is widely used to refer to Syndrome of increased epithelial permeability. The participation of Syndrome of increased epithelial permeability in the development of diseases and pathological conditions of the gastrointestinal tract, as well as the pathology of other organs and systems, is widely discussed. In early 2021, the first multidisciplinary national consensus “Syndrome of increased epithelial permeability in clinical practice” was published, and in 2022, practical recommendations for physicians were published on one of the topical aspects of Syndrome of increased epithelial permeability – epithelial protective therapy. Of the epithelial protectors used in gastroenterology, only rebamipide has a universal positive effect on the barrier function of the gastrointestinal tract throughout its entire length and at three structural levels (preepithelial, epithelial, and subepithelial). As part of the review, experimental and clinical studies, systematic reviews on Syndrome of increased epithelial permeability and the use of rebamipide, published in domestic and foreign literature in 2022, were considered. Separately, the issues of the use of rebamipide in diseases of the cardiovascular system, its protective effect and the ability to level possible problems associated with drug therapy in terms of increasing its safety in the practice of internists (cardiologist and therapist) and surgeons (cardiac surgeon and vascular surgeon) are considered. The data presented in the review demonstrate the comorbidity of the Syndrome of increased epithelial permeability, which takes a certain part in the development of diseases not only of the digestive system, but also of non-gastroenterological diseases, in particular, the pathology of the cardiovascular system, which suggests the formation of new therapeutic strategies, the use of which will improve the clinical prognosis.

Impact of Postsurgical Opioid Prescription Reduction in General Surgery Patients.

Purpose: Recent studies suggest a large percentage of post-surgical opioid prescriptions are not utilized. This surplus of opioids provides supply for diversion or entry into the waste cycle. Recommendations are available for general surgery procedures which may optimize prescribed quantity while maintaining patient satisfaction which this work was initiated to investigate. Methods: This retrospective patient survey was conducted with Institutional Review Committee approval following adjustments to discharge opioid prescription quantities in an individual General Surgeon practice. Patients were contacted via phone to assess the impact of the reduced opioid quantities. Patients were categorized based on whether they utilized the entire prescription or opioid remained. Data collected include baseline demographics, inpatient stay characteristics, opioid use patterns, and satisfaction with overall pain control. The primary endpoint was to determine if patients were satisfied with their pain control based on response. Secondary endpoints included if patient characteristics could be identified that signal larger opioid quantity use, and whether unused opioids were disposed. Results: Thirty patients utilized all opioid prescribed, 60 had some quantity remaining. Baseline data appear similar aside from age with younger patients using more opioid. Patients were satisfied with their overall pain control in 93% of respondents. A total of 960 opioid tablets (11.4 ± 4.8 tabs/patient) were not prescribed, 8% required refill. Opioid disposal yet to occur in 85% of patients. Conclusion: An evidence-based reduction in opioid discharge prescriptions following general surgery procedures resulted in nearly 1000 opioid tablets not being dispensed without having a negative impact on patient satisfaction.

One-stage transcrotal orchidopexy in bilateral inguinal cryptorchidism in children

BACKGROUND: The frequency of cryptorchidism varies and depends on gestational age, affecting 1.04.6% of full-term and 1.145% of preterm newborns. Treatment of this defect is currently surgical. Orchiopexy is one of the frequent surgical aids in the practice of a pediatric surgeon and a pediatric urologist. The need for bilateral inguinal cryptorchidism to perform several incisions or separate operations on each side by time forces pediatric surgeons to continue searching for the optimal way to correct bilateral cryptorchidism.&#x0D; AIM: To determine the possibilities of fixation of both testicles with bilateral cryptorchidism in a physiological position in the scrotum through a single surgical approach with fewer complications and improved cosmetic result in comparison with the previously proposed methods.&#x0D; MATERIALS AND METHODS: From 2012 to 2021, we treated 92 male children with bilateral inguinal cryptorchidism. All boys underwent the developed method of single-stage transcrotal bilateral orchiopexy, accompanied, if necessary, by laparoscopic assistance using the method of single-acar laparoscopic access.&#x0D; RESULTS: The results of treatment of 92 children with bilateral inguinal cryptorchidism (184 gonads) in several clinics using this method are presented. Thanks to the improvement of the technology of orchiopexy in the form of single-acar laparoscopic assistance in cases that do not allow the testicle to be freely lowered into the scrotum, the number of complications associated with surgical access, such as pronounced postoperative edema and inflammation of the postoperative wound area, decreased to 1.62% of cases, and there were no relapses of the disease and persistent inguinal hernias.&#x0D; CONCLUSIONS: The article describes a new method of single-stage transcrotal orchiopexy with laparoscopic assistance and statistically substantiates its use in bilateral inguinal cryptorchidism, which allows fixing both testicles in a physiological position in the scrotum at any position of the testicles in the inguinal region with fewer complications and improved cosmetic result in comparison with the previously proposed methods.

Routine Pathologic Examination of the Femoral Head in Total Hip Arthroplasty: A Survey Study of the American Association of Hip and Knee Surgeons

BackgroundCurrent literature does not provide conclusive evidence on whether routine pathologic examination of femoral heads from total hip arthroplasty is indicated or cost-effective. As a result, there is substantial variation in opinion among surgeons related to this issue. Our study aim was to determine factors that impact surgeon propensity to order pathologic examination of femoral heads. MethodsA 12-question survey was created to evaluate surgeon practices, indications, and patient care implications surrounding routine pathologic examination of femoral heads. The email survey was distributed to all members of the American Association of Hip and Knee Surgeons (n = 2598). ResultsThere were 572 survey respondents. Out of all respondents, 28.4% always send femoral heads to pathology, and 27.6% reported an institutional requirement to do so. Of the 572 surgeons, 73.6% report femoral head pathology has never resulted in a change in patient disease course. Factors that increase the likelihood of surgeons ordering femoral head pathologic examination include institutional requirements, medicolegal concern, and prior experience with femoral head pathologic examination changing patients' disease course (P < .001). Cost concern decreases the likelihood of surgeons ordering femoral head pathologic examination (P = .0012). ConclusionsA minority of surgeons routinely send femoral heads from total hip arthroplasty for pathologic examination, mostly because of institutional requirement. The majority of surgeons feel that femoral head pathologic examination never changes patient management, although others have infrequently detected malignancy and infection. Institutional policy, concern for litigation, and prior experience with discordant pathologic diagnoses increase femoral head pathologic examinations, while cost concern decreases them.

Changes in Personal Protective Equipment Practices of Craniofacial Surgeons during COVID-19: A Cross-sectional Study.

Two identical electronic survey studies, one in 2020 and one in 2022, were conducted on the use of PPE before, during, and after the pandemic among active craniomaxillofacial surgeons. Statistical changes in behaviors and preferences and differences across time points and demographic groups were evaluated. The initial study included responses from 48 surgeons, and the follow-up study consisted of 36 responses. Although only 4.3% of surgeons wore N95 masks or powered air purifying respirator for craniomaxillofacial operations before the pandemic, 91.5% wore these measures during the early pandemic (P < 0.001). However, this fell to 74.3% 2 years later. Similarly, more than 95% of surgeons wore a mask in clinic during the pandemic at both time points compared to only 40.3% before the pandemic (P < 0.001). In 2020, 31.9% of surgeons planned to continue using N95 masks or powered air purifying respirator for craniofacial cases after the pandemic was over, but that fell to 11.4% in the follow-up study. Craniofacial surgeon practices have shifted significantly toward more protective PPE over the course of the coronavirus disease 2019 pandemic. However, this effect was dampened over the course of a protracted pandemic. Despite this, our studies indicate a long-term shift in surgeon preference that is likely to persist after the pandemic is over.

Evolution and Trends of Facial Plastic Surgery and Facial Aesthetic Procedures in India: From Awakening to Revival.

Abstract Facial aesthetic surgery is an emerging branch worldwide. India, a torchbearer country in facial plastic surgery, has seen tremendous growth in medical technology, resources, and clientele over the past century. This study aims to study past practices and current trends in facial plastic surgery and aesthetic procedures in India by individually addressing commonly performed nonsurgical procedures (Botox, Kybella [Allergan, Irvine, CA], fillers, threads, micro-focused ultrasound, and nonsurgical hair restoration), and surgical procedures (rhinoplasty, blepharoplasty, hair transplant, and facelift). It also aims to further elaborate on the scope of facial aesthetics and make recommendations on prospects in the field. A structured scoping review and a subsequent evidence-based synthesis were done following an extensive literature search on various databases such as PubMed (National Institutes of Health, Bethesda, MD), LILACS (Latin American and Caribbean Center on Health Sciences Information, São Paulo, Brazil), MEDLINE (National Library of Medicine, Bethesda, MD), EMBASE (Elsevier, Amsterdam, the Netherlands), and Cochrane (Wiley, Hoboken, NJ). The initial search yielded 703 articles, out of which 20 were found to be relevant to the present study and discussed. It was found that there is an upward trend in the growth of facial plastic surgery in India, and a gradual shift in patient attitude toward nonsurgical aesthetic procedures was seen. This article affirms the growth of facial aesthetic surgery in India by highlighting the recent development and trends in the practices of surgeons. It also addresses the shortcomings in the current administration and makes recommendations to fill the existing loopholes in plastic surgery. Level of Evidence: 5

Predictors of Intraoperative Echocardiography: Analysis of The Society of Thoracic Surgeons Database

BackgroundIntraoperative transesophageal echocardiography (TEE) is associated with improved outcomes after cardiac surgery, but unexplained practice pattern variation exists. This study aimed to identify and quantify the predictors of intraoperative TEE use among patients undergoing isolated coronary artery bypass graft surgery (CABG) or cardiac valve surgery. MethodsThis observational cohort study used The Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database data to identify and quantify the predictors of intraoperative TEE use among adult patients aged 18 years or more undergoing either isolated CABG or open cardiac valve repair or replacement surgery between January 1, 2011, and December 31, 2019. Generalized linear mixed models were used to measure the relationship between intraoperative TEE and patient characteristics, surgical volume, and geographic location, while accounting for clustering within hospitals (primary analysis) or surgeons (secondary analysis). ResultsOf 1,973,655 patients, 1,365,708 underwent isolated CABG and 607,947 underwent cardiac valve surgery. Overall, intraoperative TEE was used in 62% of surgeries. The primary hospital-level generalized linear mixed models analysis demonstrated that the strongest predictor of intraoperative TEE use was the hospital where the surgery occurred—with a median odds ratio for TEE of 10.13 in isolated CABG and 5.30 in cardiac valve surgery. The secondary surgeon-level generalized linear mixed models analysis demonstrated similar findings. ConclusionsIntraoperative TEE use (vs lack of use) during surgery was more strongly associated with hospital and surgeon practice patterns than with any patient-level factor, surgical volume, or geographic location.

Declining Geographic Access to High-Volume Revision Total Hip Arthroplasty Surgeons: A National Medicare Analysis

BackgroundWhile trends in the economics of revision THA (revTHA) procedures have been well-described from the standpoint of both hospitals and surgeons, their population-level effects of these trends on patient access are not well-understood. MethodsThe Medicare fee-for-service provider utilization and payment public use files were used to extract data for primary and revTHA for beneficiaries between 2013 and 2019. Primary and revTHA procedures were identified using the Healthcare Common Procedure Coding System code; 27130 for primaries and 27132, 27134, 27137, or 27138 for revisions. Geospatial analyses were performed by aggregating surgeon practice locations at the level of individual counties, hospital service areas, and hospital referral regions. ResultsThe number of high-volume primary THA surgeons within the Medicare population increased by 17.6% over the study period (3,838 in 2013 to 4,515 in 2019). Conversely, the number of high-volume revTHA surgeons decreased by 36.1% (178 in 2013 to 129 in 2019). Linear regression revealed a significant increase and decrease in high-volume primary (β = 109.07, P ≤ .001) and revision (β = −13.04, P = .011) THA surgeons, respectively. Over the study period, the number of counties with at least 1 high-volume primary THA surgeon increased by 6.1% (1,194 to 1,267), while the number of counties with at least 1 high-volume revTHA surgeon decreased by 30.2% (159 to 111). ConclusionThe present findings of declining geographic access may represent a consequence of shifting economic incentives and declining reimbursements for the care of complicated revTHA patients.

Exploring what is reasonable: uncovering moral reasoning of vascular surgeons in daily practice

BackgroundVascular surgery offers a range of treatments to relieve pain and ulcerations, and to prevent sudden death by rupture of blood vessels. The surgical procedures involve risk of injury and harm, which increases with age and frailty leading to complex decision-making processes that raise ethical questions. However, how vascular surgeons negotiate these questions is scarcely studied. The aim was therefore to explore vascular surgeons’ moral reasoning of what ought to be done for the patient.MethodsQualitative, semi-structured interviews were conducted with 19 vascular surgeons working at three Swedish university hospitals. Data were analysed according to systematic text condensation.ResultsThe surgeons’ moral reasoning about what ought to be done comprised a quest to relieve suffering and avoid harm by exploring what is reasonable to do for the patient. Exploring reasonableness included to shift one´s perspective from the vessels to the whole person, to balance patient’s conflicting needs and to place responsibility for right decision on one´s shoulders. The shift from blood vessels to the whole person implied gaining holistic knowledge in pondering of what is best, struggling with one´s authority for surgery through dialogue, and building relationship for mutual security. To balance patient’s conflicting needs implied weighing the patient’s independence and a sense of being whole against ease of suffering, respecting the patient’s will against protecting life and well-being, and weighing longer life against protecting the present well-being. Finally, to place responsibility on one´s shoulders was conveyed as an urge to remind oneself of the risk of complications, withholding one’s power of proficiency, and managing time during the illness course.ConclusionsThis study contributes to uncovering how moral reasoning is embodied in the vascular surgeons’ everyday clinical discourse as a tangible part of their patient care. The results underpin the significance of moral considerations in the assemblage of medical knowledge and technical skills to further understand vascular surgeons’ clinical practice. The clinical application of these results is the need of forums with sufficient possibilities for articulating these important moral considerations in everyday care.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction.

The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. Level V.

Generalized form of tularemia in pediatric surgeon practice: Difficulties of diagnosis and treatment

Tularemia in the practice of a pediatric surgeon is a rare disease, and abdominal and generalized forms of it are not detected without specific laboratory diagnostics. The long-term serious condition of patients, intoxication, abdominal pain with excluded acute surgical pathology in children force differential diagnosis with rare infectious diseases, including tularemia. In the Russian Federation, up to 30 children a year are diagnosed with tularemia, with the exception of outbreaks of the disease in some years. At the same time, the generalized form is detected in no more than 10% of patients. The authors presented a clinical case of a generalized form of tularemia in a 17-year-old patient. The disease started with abdominal pain, diarrhea and vomiting. At the beginning of the disease, a diagnostic error was made — suspicion of ovarian inversion and laparotomy according to Pfannenstiel. In the further development of the disease, pronounced ascites were detected with the production of up to 5 liters of effusion per day, damage to the kidneys, liver, heart, gastrointestinal tract. Laboratory data revealed leukocytosis up to 89×109, accelerated erythrocyte sedimentation rate, increased levels of creatinine, urea, transaminases, C-reactive protein, proteinuria persisted for a long time. Indirect hemagglutination reaction with tularemia diagnosticum made it possible to establish the diagnosis of tularemia, generalized form. During two weeks of the disease, an 8-fold increase in the titer of antibodies was noted. Syndrome therapy and specific antibacterial therapy made it possible to stop the infectious process and discharge the patient home on the 44th day of the illness with recovery.

Multiple Arterial Graft Use in Coronary Artery Bypass Surgery: Surgeon Perspective vs Practice

BackgroundDespite supportive evidence and guidelines, the use of multiple arterial grafts (MAGs) in coronary artery bypass grafting remains low. We sought to determine surgeon perception of personal MAG use and compare this with actual MAG use. MethodsWe conducted a statewide surgeon survey of MAG use, presence of a hospital MAG protocol, and barriers for MAG use, with a response rate of 78% (n = 25). Surgeon survey responses were compared with actual Society of Thoracic Surgeons patient data from January 1, 2017, to December 31, 2020 using χ2 or Fisher’s exact tests. ResultsOf 5299 patients who had first-time, nonemergent, isolated coronary artery bypass grafting (≥2 grafts) by responding surgeons, 16% received MAG (n = 825). MAG use in patients whose surgeons self-designated as “routine” MAG users was 21% vs 7% for “nonroutine” users. Surgeons with a hospital protocol for MAG use utilized MAG more often (18% vs 14%, P = .001). Surgeons who were unconvinced by the data on the benefits of MAGs used MAGs in 11% vs 22% in surgeons who were convinced. MAG use increased over time, particularly from before to after the survey (13.1% vs 30.5%, P < .001). ConclusionsAlthough MAG use increased over time, barriers to routine use remain. In surgeons who reported routine use, only 21% of their patients received MAGs. Hospital protocols, education, and increased awareness may reduce barriers to use and encourage evidence-based clinical practice.

Characterizing the geographic distribution of vascular surgeons in the United States.

The shortage of vascular surgeons can be attributed to multiple factors, including an aging population, the increasing demand for vascular surgeons, and an aging vascular surgery workforce. The distribution of vascular surgeons across the United States varies by locale; thus, the shortage affects regions of different sizes disproportionately. We collated the geographic data to characterize the current distribution of vascular surgeons with an emphasis on the practice location, population density, and population age. Vascular surgeons were identified using the Physician Compare National Downloadable file from the Centers for Medicare and Medical Services. The counties were matched with each surgeon's practice location. The locations were categorized into metropolitan, urban, or rural using the rural-urban continuum codes. Census Bureau data were used to match all counties with their population-level metrics. The distribution of vascular surgeons was analyzed by comparing the number of counties served, total patient population served, and patient population aged >50 and >65years served. Finally, the density of vascular surgeons in the United States for the total population and for those aged >50 and >65years was calculated. In 2018, the U.S. population was 309.8 million, and there were 3145 counties. Of the 3145 counties, 533 (17%) had had a practicing vascular surgeon. The combined population of these counties was 213.8 million people (69% of the U.S. population). Stratified by age, the vascular surgeons in these 533 counties could treat 37.3 million people aged >50years and 17.4 million people aged >65years. However, 2612 counties (83%), with a total population of 96 million people (31% of the U.S. population), had had no practicing vascular surgeon. When stratified by age, 78.1 million people in the uncovered counties were aged >50years and 35 million were aged >65years. Of the 2612 uncovered counties, 48% were urban and 24% were rural. We found a nationwide shortage of vascular surgeons, with urban and rural areas disproportionately affected negatively. Although encouraging vascular surgeons to practice in underserved areas would be an ideal solution, it is not pragmatic. Therefore, developing alternatives such as using primary care providers, investing in telehealth and developing transfer systems could be viable methods of providing vascular care to geographically isolated populations. These findings have significant implications for hospitals, patients, and vascular surgeons, who would all stand to benefit from efforts to address these disparities.