23.02 A National Survey of Sexual Harassment Among Surgeons

Posted on January 31, 2019

A. Nayyar1, S. Scarlet1, P. D. Strassle1, D. W. Ollila1, L. M. Erdahl3, K. P. McGuire2, K. K. Gallagher1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA 3University Of Iowa,Department Of Surgery,Iowa City, IA, USA

Introduction:

Emerging data suggests that experiencing sexual harassment in the workplace is a common occurrence for women across all professions, which can be harmful personally and professionally.  While recent studies have reported the incidence of sexual harassment in medicine, no study has examined the nature or scope of sexual harassment experienced by surgeons.

 

Methods:

An anonymous, electronic survey was distributed via a web-based platform to members of American College of Surgeons (ACS), Association of Women Surgeons (AWS), and through targeted social media platforms from April-July 2018. Questions pertained to workplace experiences and frequency of sexual harassment in the past 12 months. Sexual harassment was defined according to the U.S. Equal Employment Opportunity Commission. Fisher’s exact and Mantel-Haenszel tests were used to assess differences in respondent characteristics.

Results:

1,005 individuals completed the survey. 74% (n=744) identified as women, a response rate of 18% among US women surgeons. 25% (n=249) of respondents identified as men which represents 1% of male surgeons in the US – these responses were analyzed separately. Respondents reported employment by an academic institution (51%), community medical center (13%), private practice (15%), or other (19%). For both genders, the most common specialties were general surgery (34%), trauma surgery (10%), and surgical oncology (8%). Overall, 58% (n=432) of women surgeons experienced sexual harassment within the 12-month period preceding the survey, compared to 25% (n=61) of men, p<0.0001. Among women, the most common forms of harassment reported were “verbal or physical conduct (e.g. body language)” (53%), “unwanted sexual advances or physical contact” (23%), and “comments about sexual orientation” (10%). Women trainees were more than twice as likely to experience harassment as compared to attending surgeons (OR 2.52, 95% CI 1.78, 3.56, p<0.0001). The majority (84%) of incidents of harassment reported by women as part of the survey were not reported to any institutional authority. The most common reasons for not reporting was “fear of a negative impact on my career” (43%), “fear of retribution” (32%), and “fear of being dismissed and/or inaction towards perpetrator” (31%) (Figure).  

Conclusion:

Our study indicates that there is an alarming prevalence of unreported sexual harassment experienced by women surgeons in the US.   Combined with the documented sexual harassment of women physicians in other medical specialties, we believe this finding demonstrates an urgent need to improve the safety of the healthcare workplace, not just for women surgeons, but for all.
 

21.03 Tissue Factor-Targeted Peptide Amphiphile as an Injectable Therapy for Hemorrhage

Posted on January 31, 2019

M. Klein1, H. Kassam1, M. Karver2, M. Struble2, L. Palmer2, N. Tsihlis1, S. Stupp2, B. Gavitt4, T. Pritts3, M. Kibbe1  1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA 2Northwestern University,Chicago, IL, USA 3University Of Cincinnati,Cincinnati, OH, USA 4United States Air Force School of Aerospace Medicine,Cincinnati, OH, USA

Introduction: Non-compressible torso hemorrhage is a leading cause of preventable death in civilian and battlefield trauma. We sought to develop a tissue factor (TF)-targeted nanofiber that can be given intravenously to slow hemorrhage until definitive bleeding control can be obtained.  TF was chosen because it is only exposed to the intravascular space upon vessel disruption. Peptide amphiphile (PA) monomers that self-assemble into nanofibers were chosen as the delivery vehicle.  Here, we systematically analyzed the binding interface of TF to factor VII to generate a TF-binding sequence.  We hypothesize that TF-targeted nanofibers will localize to the site of bleeding in a liver hemorrhage model.

Methods:  PA monomers were synthesized by solid-phase peptide synthesis, purified by high pressure liquid chromatography (HPLC), and characterized by HPLC-mass spectrometry (HPLC-MS).  A TF-binding sequence SFEEARE (SFE) was added to the PA backbone.  SFE-PAs (75% by weight) were co-assembled with PA backbone (20%) and a fluorescently labeled TAMRA PA (5%) to create TF-targeted nanofibers.  Non-targeted PA nanofibers served as controls.  Nanofiber formation was assessed via conventional transmission electron microscopy (TEM) and structure by circular dichroism (CD) spectroscopy.  Male Sprague Dawley rats (250-290g) underwent a liver punch hemorrhage model in which the liver was exposed via a midline laparotomy, followed by tail vein injection of the nanofiber (2.5mg).  A 12mm biopsy punch was used to injure the left lateral lobe of the liver.  Shed blood was collected with pre-weighed gauze for 30 minutes and expressed as percent of total blood volume.  Data are presented as mean±SEM and analyzed by ANOVA.

Results: PAs were >95% pure, as shown by HPLC-MS.  Co-assemblies of PAs formed nanofibers, as shown by TEM, and displayed the expected β-sheet signal characteristic of PA nanofibers when analyzed by CD spectroscopy.  Injection of the SFE-PA nanofiber demonstrated binding to the site of liver injury using fluorescent microscopy, with uninjured liver showing minimal fluorescence and control nanofibers showing minimal fluorescence.  Somewhat surprisingly, given that there was no therapeutic molecule on the PA nanofiber, total blood loss for rats that received the SFE-PA nanofiber was 36% lower than sham rats (14.5±0.95% vs. 22.8±1.1%, n=6, P<0.05).  Blood loss for rats injected with the non-targeted PA nanofiber was similar to sham rats (21.59±2.8%, n=6).

Conclusion: We have successfully synthesized, purified, and characterized a novel PA nanofiber that targets sites of active bleeding in a rat model of hemorrhage.  Not only did our injectable TF-targeted PA nanofiber localize to the site of injury, it appears to decrease blood loss in the setting of abdominal hemorrhage. Incorporation of a therapeutic agent will make this promising technology even more effective in treatment of non-compressible torso hemorrhage.

 

14.20 Evaluation of Growth Outcomes in Pediatric Cerebral Palsy Patients with Gastrostomy Tubes

Posted on January 31, 2019

J. Jadi1,2, N. Rodriguez-Ormaza3, R. Maine1, A. Charles1, E. Hoke1, T. Reid1  1University Of North Carolina At Chapel Hill,General And Acute Care Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,School Of Medicine,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,School Of Public Health,Chapel Hill, NC, USA

Introduction:  Malnutrition as a result of feeding difficulties is a common complication in children with cerebral palsy. There are currently few studies looking at interventions for malnutrition and which ones have the best growth outcomes for pediatric cerebral palsy patients. The goal of this study was to examine characteristics of cerebral palsy patients undergoing gastrostomy tube placement and assess the growth outcomes after 3 months, 6 months, and 1 year.

Methods:  This study was a retrospective study of all pediatric patients with cerebral palsy under the age of 18 who received a gastrostomy tube placement between April 2014-December 2017 at UNC Hospital.  Baseline information was collected, including age, sex, degree of malnutrition, comorbidities, change in weight and z scores over time, nasogastric (NG) tube placement, and prior gastrostomy tube placement. The primary outcome was weight gain at 3 months, 6 months, and 1 year. Secondary outcomes included mortality and complications. Bivariate analysis and a proportional odds model were used to examine the association between increase in weight (based on quantiles) and patient characteristics at 3 months, 6 months, and 1 year. 

Results: Out of the 63 patients who received a gastrostomy tube, 30 (47.6%) were female, with a mean age of 4.3 months +/- 4.9. Almost all patients (98.8%) had at least one comorbidity. At the time of placement, 11.8% of patients had mild malnutrition, 29.4% had moderate malnutrition, and 58.8% had severe malnutrition. A majority of 53 (94.6%) patients had their tube placed laparoscopically, while the rest were placed open. Greater increases in weight at all time intervals were significantly associated with younger age, adjunct NG tube, and longer length of hospital stay after adjusting for confounders. Patients weight changes tracked at 3 months, 6 months, and 1-year post gastrostomy placement showed an overall weight increase for 98% of patients. Forty-six percent of patients had at least one gastrostomy tube related complication, 23.8% had two complications, and 4.76% had 3 or more with the most common complications being minor tube functional issues (43.6%), such as clogging, leakage, or tube dislodgment. 

Conclusion: The use of gastrostomy tubes for malnutrition in cerebral palsy patients resulted in an increase in weight for the majority of patients over the course of a year. Although the majority of complications were minor, patients had a high complication rate.  Given the high complication rate and the significantly increased weight gain in younger patients who were hospitalized longer and who had NG tubes, further studies should be conducted to evaluate if certain patients might benefit from longer trials of NG tube nutrition.

11.02 Aggregation and Linkage of Multiple Data Sources for Pragmatic Observational Study Designs

Posted on January 31, 2019

A. C. Allori1,6, E. Le7, B. A. Goldstein5,6, J. Hurst6, J. Vissoci10,11, J. Routh8, H. Bosworth9, A. Drake3, J. Wood2, L. David4, A. C. Allori1,6  1Duke University Medical Center,Plastic Surgery,Durham, NC, USA 2University Of North Carolina At Chapel Hill,Plastic Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Otolaryngology,Chapel Hill, NC, USA 4Wake Forest University School Of Medicine,Plastic Surgery,Winston-Salem, NC, USA 5Duke University Medical Center,Biostatistics,Durham, NC, USA 6Duke University Medical Center,Children’s Health & Discovery Initiative,Durham, NC, USA 7Duke University Medical Center,School Of Medicine,Durham, NC, USA 8Duke University Medical Center,Urology,Durham, NC, USA 9Duke University Medical Center,Population Health Science,Durham, NC, USA 10Duke University Medical Center,Global Health,Durham, NC, USA 11Duke University Medical Center,Neurosurgery,Durham, NC, USA

Introduction:
Population-health research — whether observational studies, pragmatic clinical trials, or dissemination and implementation science — requires a great deal of data infrastructure and management. Many different data sources must be aggregated and linked in order to answer the research questions at hand. Often, the data from one source are vastly different from, and possibly incompatible with, those from other sources. One promising method of dealing with such data interoperability challenges is to defining project-specific data schemas as expansions to a "common data model" (CDM). In this project, we describe the specific use case of linking disparate data sources related to cleft lip/palate in order to facilitate epidemiologic and health-services research queries.

Methods:
Raw data were obtained from North Carolina Birth Defect Monitoring Program (NCBDMP), Patient-Centered Outcomes Research Network (PCORnet), hospital electronic health records (EHR), and a condition-specific outcomes registry (CleftKit). A project-specific schema was defined following the PCORnet CDM with further inspiration from other common systems (e.g., PEDSnet and OMOP CDM and HL7 FIHR interoperability standards). Structured data were extracted from each raw source, transformed, and loaded (ETL) into a relational database (PostgreSQL/PostGIS) according to this schema, and unstructured data were stored in a parallel document database (MongoDB). Data linkage and deduplication were performed using retained PHI and/or statistical matching. A custom API was programmed in Python to facilitate clinical queries and exploratory analysis. Best practices of software development and reproducible research were followed, including use of version control for code stability, virtual environments and containers for reproducibility, Jupyter notebooks for exploration and communication, and use of highly tested open-source software.

Results:
The PCORnet CDM provides a robust yet extensible backbone upon which to build project-specific data architectures. By following PCORnet CDM design, it was possible to link data from several different data sources. The robust CDM-based project schema greatly facilitated the process of performing a variety of queries and analyses, ranging from epidemiologic description to network analysis to geostatistical analysis. 

Conclusion:
This proof-of-concept investigation demonstrates that it is possible to use a Common Data Model (CDM) as the foundation for condition-specific pragmatic research, effectiveness research, implementation science, and collaborative quality-improvement programs. The next step is to build API-driven pipelines that automatically digest data from original sources in realtime, thus performing the ETL process "in the cloud" and "bringing the analysis to the data, rather than the data to the analysis." This will be important for scaling analysis from typical large databases, as used here, to truly Big Data.
 

101.08 The Epidemiologic Characteristics and Outcomes of Intentional Burn Injuries at a Regional Burn Center

Posted on January 31, 2019

K. D. Atwell1, C. Bartley1, B. Cairns1, A. Charles1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA

Introduction: The predictors of burn mortality have been well studied, which include age, burn size, presence of inhalational injury and pre-existing comorbidities. There are limited studies that describe the role of burn injury intentionality on mortality outcome. Intentional burn injury outcomes are usually more severe, have a high mortality and are seen more often in low and middle income countries.1,2 This study will examine the epidemiological characteristics of intentional burn injury patients and mortality outcome at the UNC Jaycee Burn Center in North Carolina.

Methods: A retrospective study of patients admitted to the UNC Jaycee Burn Center from 2002-2015. Variables analyzed were basic demographics, total body surface area (TBSA) of burn, type of burn, presence of inhalation injury, Charlson comorbidity index (CCI), burn intent, mortality and intensive care unit (ICU) and hospital length of stay (LOS). Chi-square tests, bivariate analysis and logistic regression models were used to determine statistical significance between the two study groups.

Results:11,786 adult and pediatric patients from 2002-2015 were included in the study. 348 (3%) patients had intentional burn injuries (IBI). Patients with IBI had a lower mean age of 26.5 ±20.4 vs. 32 ±22 in the non-intentional burn injury (NIBI) group, p<0.001.  Mean %TBSA was significantly higher in the IBI vs. NIBI group at 14.6 ±20 vs. 6.4 ±10, p<0.001, respectively. Non-whites (66%) were more likely to have IBI compared to Whites (34%), p<0.001. Inhalation injury and mortality were statistically significant in the IBI burn cohort, 16% (n=54) and 9% (n=30), respectively vs. 6% (n=647) and 2.9% (n=329) in the NIBI group, respectively, p<0.001. Median hospital LOS was significantly higher in IBI patients compared to NIBI patents, 10 days (IQR=22) vs. 5 days (IQR=10), p<0.001. Median ICU LOS was also significantly higher in IBI patients compared to NIBI patents, 7 days (IQR=33) vs. 3 days (IQR=10), p<0.001. Multivariate logistic regression for odds ratio showed that IBI patients have a 2.6x increased odds of mortality, an increased hospital LOS of over twice the mean LOS and a prolonged ICU LOS 1.6x over the mean ICU LOS.

Conclusion:Our study findings showed that patients with intentional burn injuries have high burn injury severity attributable to the associated increased %TBSA and Inhalation injury. Furthermore, patients with intentional burn injury have higher odds of mortality and increased ICU and hospital LOS. Intentional burns, both self-harm or assault burns, increase health care expenditures attributable to additional resources for medical, psychiatric, social services and other health care expenses.  There must be a high index of suspicion for intentional injury for large %TBSA burn and associated inhalation injury. Violence prevention initiatives that target the male and minority demographic may be beneficial in reducing intentional burn injury burden.

101.06 Amputation Following Burn Injury

Posted on January 31, 2019

C. N. Bartley1, K. Atwell1, B. Cairns1, A. Charles1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction: Amputation following burn injury is a rare occurrence. Nevertheless, the physical, psychological, and socioeconomic consequences are substantial. Previous studies describe the risk of amputation after electrical burn injuries and/or only involve a small number of patients. Therefore, we will describe the distribution of amputations and evaluate for predictors of amputation after burn injury for all burns admitted to a large regional burn center.

Methods:  We conducted a retrospective analysis of patients ? 17 years admitted from January 2002 to December 2015. Baseline patient and injury characteristics included sex, age, %TBSA, race, burn etiology, and the presence of a concomitant inhalation injury. Patients who underwent an amputation procedure were compared to those who did not. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by location (upper vs lower extremity) and type (major vs minor) for comparison. Additionally, patient characteristics of those who underwent an amputation procedure were compared by etiology (electrical vs thermal) to assess for potential differences.

Results: Of the 8,313 patients included for analysis, 1.4% underwent an amputations(s) (n = 119). Amputees were older (46.7 ± 17.4 years) than patients with no amputations (42.6 ± 16.8 years) (p = 0.009). Black (39.5%) and Hispanic (8.4%) patients were more likely to have an amputation procedure. The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Median CCI was 0 for both the amputation and no amputation patients (p = 0.030). Patients in the amputation group had a higher median TBSA compared to those in the no amputation group (6% vs 3%, p <0.001). Black race (OR 2.29; 95% CI 1.22 – 4.30), CCI (OR 1.29; 95% CI 1.05 – 1.59), electric (OR 13.54; 95% CI 6.23 – 29.45) and other (OR 4.24; 95% CI 1.84 – 9.81) burn etiology, and %TBSA (OR 1.03; 95% CI 1.02 – 1.05) were found to be associated with an increased odds of amputation.

Conclusion: Our study confirms previous findings that electrical burns are associated with an increased risk of amputation. We also found that other burn types, the presence of pre-existing comorbidities, black race, and increased %TBSA are predictors of amputation in a population of burn patients admitted to a regional burn center. The role of comorbidities and race on the risk of amputation requires further investigation.

 

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