81.10 Safety and Feasibility of Trileaflet Aortic Valve Reconstruction: A Case Control Study

Posted on January 26, 2017

P. Chan1, E. Chan1, D. Chu1  1University Of Pittsburgh School Of Medicine,Cardiothoracic Surgery,Pittsburgh, PA, USA

Introduction: Aortic valve replacement (AVR) has been considered the gold standard for surgical treatment of calcific aortic stenosis (AS).  However, the prostheses used for replacement are not perfect.  Recently, there has been an influx of techniques to reconstruct the aortic valve.  We hypothesize trileaflet aortic valve reconstruction using autologous pericardium (AVRec) is safe and feasible compared to conventional AVR with prostheses. 

Methods: In a single quaternary referral institution, 8 patients underwent AVRec with autologous pericardium between January 2015 and July 2016.  6 patients underwent isolated AVRec and 2 patients underwent AVRec + coronary artery bypass grafting (CABG).  After initiating cardiopulmonary bypass and excising the native diseased valve cusps, the glutaraldehyde-treated pericardium is fashioned into neo-cusps following a template after measurements are done with sizers.  To compare AVRec vs. AVR, we performed 1:1 matched AVRec patients with those undergoing conventional AVR+/-CABG according to age, preoperative ejection fraction (EF), aortic valve area (AVA) and baseline creatinine (Cr).

Results: The mean age, preoperative EF, AVA and baseline Cr for AVRec was 68.1±3.6 years, 60.8±1.2%, 0.79±0.07 cm² and 0.96±0.05 vs. for AVR, 65.5±4.4 years, 57.5±1.2%, 0.83±0.02 cm² and 1.0±0.07, respectively.  AVRec required longer perfusion and myocardial ischemic times compared to AVR (178.1 and 153.5 minutes, p=.50 vs. 119.6 and 97.6 minutes, p=.015).  Post-operative EF did not change significantly in all patients undergoing either AVRec or AVR.  Length of stay (LOS) was also not statistically different, with both groups being discharged in a mean of 6.5 days (p=.959).  All AVRec patients had either none or trace aortic insufficiency (AI) on immediate and 1 to 3 month postoperative echocardiography, with no valvular failures or reoperations.  Aortic valve gradients were slightly improved with AVRec compared to AVR with peak gradients being 11 vs 17.4 mmHg (p=.093), respectively, and mean gradients being 6.75 vs, 9.4 mmHg (p=.171), respectively (Table 1).  There were no differences in postoperative complications such as atrial fibrillation, acute kidney injury and pleural effusions.       

Conclusions: Aortic valve reconstruction requires no use of foreign material.  Short-term postoperative results for AVRec were comparable to conventional AVR with none or trace AI.  This novel technique is a feasible and safe option for the treatment of calcified AS.

 

80.14 Hand to Hand Coupling: A Novel Mechanism of Unintentional Energy Transfer

Posted on January 26, 2017

D. M. Overbey1,2, S. A. Hilton1, N. T. Townsend1, B. C. Chapman1, C. D. Raeburn1,2, T. N. Robinson1,2, E. L. Jones1,2  1University Of Colorado,Surgery,Aurora, CO, USA 2Denver Veterans Affairs Hospital,Surgery,Denver, CO, USA

Introduction: Energy-based devices are used in nearly every laparoscopic operation. Radiofrequency energy can transfer to nearby instruments via antenna and capacitive coupling without direct contact. Previous studies have described inadvertant energy transfer through bundled cords and nonelectrically active wires.  The purpose of this study is to describe a new mechanism of stray energy transfer from the monopolar instrument through the operating surgeon to the laparoscopic telescope, and propose practical measures to decrease the risk of injury.

Methods: Radiofrequency energy was delivered to a laparoscopic L-hook (monopolar “bovie”), an advanced bipolar device, and an ultrasonic device in a laparoscopic simulator. The tip of a 10mm telescope was placed adjacent but not touching bovine liver in a standard four-port laparoscopic cholecystectomy setup. Thermal injury was measured as increased tissue temperature from baseline nearest the tip of the telescope which was never in contact with the energy-based device after a five second activation.

Results: The monopolar L-hook increased tissue temperature adjacent to the camera/telescope tip by 47±8°C from baseline (p<0.001). By having an assistant surgeon hold the camera/telescope (rather than one surgeon holding both the active electrode and the camera/telescope), temperature change was reduced to 26±7°C (p<0.001). Alternative energy devices significantly reduced temperature change in comparison to the monopolar instrument (47±8°C) for both the advanced bipolar (1.2 ±0.5 °C; p<0.001) and ultrasonic (0.6 ±0.3 °C; p<0.001) devices.

Conclusion: Stray energy transfers from the monopolar “bovie” instrument through the operating surgeon to standard electrically inactive laparoscopic instruments.  Hand-to-Hand coupling describes a new form of capacitive coupling where the surgeon’s body acts as an electrical conductor to transmit energy (Figure 1).  Strategies to reduce stray energy transfer include avoiding the same surgeon holding the active electrode and laparoscopic camera, or using alternative energy devices.

 

80.05 A Novel Blood Coagulation Assay: Optical Detection of Clot Kinetics Between Matched Surface Areas

Posted on January 26, 2017

M. J. George1, C. Cox1, K. Aroom1, T. Sharma1, M. Skibber1, B. Gill1  1The Univeristy Of Texas Health Science Center At Houston,Department Of Surgery,Houstn, TX, USA

Introduction: Various devices exist capable of detecting platelet activity and an effect of antiplatelet therapy. However, these devices only offer qualitative data without basis in direct measurement of platelet activity. There is no existing clinical assay capable of quantitatively detecting platelet contractile forces. The purpose of this study is to create a novel assay to detect anti-platelet drug effects on clotting by measuring contractile forces of platelets in clotting whole blood.

 

Methods: After appropriate IRB approval whole blood samples were collected from healthy human subjects before and after taking 325 mg of oral aspirin. Calcium chloride was added to citrated samples to initiate clotting. Samples were placed in a temperature controlled glass test chamber with acrylic inserts of matched surface areas at the top and bottom creating a cylindrical blood sample of known height and radius. A camera recorded deflection of a bent wire attached to the top acrylic insert. Using beam equations, force generated by the contracting clot was recorded with time. Kinetic metrics such as clot activation, rate of contraction and clot volume change are recorded. Student t-tests compared metrics taken from the force curves.

 

Results: Qualitative analysis of force curves identified an activation phase prior to a clot reaching a steady state rate of contraction. Student t-tests comparing rates of steady state clot contraction demonstrated aspirinated blood contracted slower, thus generated force at a slower rate than control blood (20.24 versus 23.92 micro-Newtons per second, p = 0.032). Time to reach steady state contraction also was longer for aspirinated blood compared to control blood (588 versus 435 seconds, p = 0.043).

 

Conclusion: This novel blood coagulation assay detects force generated by platelets in a contracting clot with time and demonstrates the kinetics of blood clotting. Aspirinated blood develops force at a slower rate and takes more time to reach a steady state of contraction than control blood.

 

78.01 Comparison of pH­sensitive fluorescent nanoprobe to cetuximab­IRDye800 for realtime imaging of SCC

Posted on January 26, 2017

M. Tabata1, N. Nathan1, T. Teraphongphom1, K. Hettie2, J. Klockow2, S. Rogalla3, R. Ertsey1, E. Rosenthal1,2  2Stanford University,Radiology,Stanford, CA, USA 3Stanford University,Pediatrics,Palo Alto, CA, USA 1Stanford University,Otolaryngology – Head And Neck Cancer,Palo Alto, CA, USA

Introduction: Despite widespread acceptance of fluorescence imaging for several different types of cancer, the ideal optical imaging probe for intraoperative delineation of head and neck squamous cell carcinoma (HNSCC) margins has not yet been identified. Identification of this probe for detecting subclinical disease in tumor margins will improve oncologic surgical outcomes. This study compares a fluorescently labeled anti-­epidermal growth factor receptor (EGFR) antibody, Cetuximab-­IRDye800CW (IR800-CTM), with an ultra pH­-sensitive (UPS) fluorescent nanoprobe for detection of HNSCC.

Methods: Thirteen immunodeficient mice were inoculated with HCT. Through tail vein injections, four mice were given 200 uL of IR800-CTM at 14uM. Three were given 100 uL of UPS nanoprobes, and three were given 200 uL, both at 0.1 mg/mL. Two were given 200 uL of saline, and one was given 200 uL of IRDye800 at 28uM. Images were acquired using the Pearl® Trilogy(LI-COR) in vivo optical imaging system at 8, 22, 26, 30, 46, and 72 hours along with the SPY Elite®(Novadaq) at 72 hours. Ex vivo images were acquired using the Pearl® and Odyssey®(LI-COR). Tumor­ to ­background ratios (TBR) were calculated by dividing the intensity of the fluorescence in the tumor by that of healthy flank tissue. TBRs of the UPS nanoprobe group and the IR800-CTM group were compared. An unpaired, two-­sided Student’s T-­test with unequal variance was used to test for statistical significance.

Results: There is no statistically significant difference between TBRs of UPS nanoprobes and IR800-CTM in vivo. We can successfully image tumors in vivo and obtain TBRs of 2.81 (±0.68 SD) with UPS nanoprobes and 5.27 (±1.85 SD) with IR800-CTM. Ex vivo histology confirms fluorescence in tumors. The TBR of the UPS nanoprobes reached a maximum at 22 hours and stayed above 83% of maximum until 72 hours. The lower dose of 100µL yields stronger and more specific signal than the 200µL dose. Both UPS nanoprobes and IR800-CTM localize in kidneys and liver, and IR800-CTM shows greater tumor:liver fluorescence ratio.

Conclusion: Both UPS nanoprobes and IR800-CTM are tools for intraoperative optical visualization of cancer. The earlier TBR peak of UPS nanoprobes is clinically advantageous. Currently, complete removal of HNSCC with minimal damage to other tissues cannot be guaranteed, and improved visualization of tumor margins would improve post-­surgery oncologic outcomes. We compare two methods for optical imaging of tumor margins in HNSCC. These outcomes will help guide further investigation of an optimal optical imaging agent for HNSCC. This methodology is reproducible for investigation in other tumor types.

76.01 Web-Based Feedback for Medical Students Provides Quantitative & Qualitative Assessment of Feedback.

Posted on January 26, 2017

G. Shaughness1, P. Georgoff1, G. Sandhu1, L. Leininger1, R. Reddy1, D. T. Hughes1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:  Clinical rotations in the third and fourth years of medical school mark a shift in learning methodology from structured didactics to bedside apprenticeship. In this setting, feedback, which is traditionally verbal and not formally recorded, plays a critical role in student development. Little is known about the quantity and quality of feedback provided. This study uses a novel, web-based Minute Feedback System to evaluate feedback given to students during their core surgical clerkship.

Methods:  Content of feedback, student request rates, and resident and faculty response rates obtained from the Minute Feedback System between May 2015 and April 2016 were analyzed. Four categories were assigned to qualify feedback students received: “encouraging” praises a student’s performance, “corrective” highlights areas for improvement, “general” characterizes vague comments, and “specific” identifies concrete skills. These were then grouped by quality: “good” feedback comprised any combination of specific and either corrective or encouraging; “mediocre” included all categories without differentiation; “bad” feedback was defined as general combined with either encouraging or corrective. Responses were attributed to surgery residents of differing training levels and to faculty members, which were analyzed as a whole and separately. Significant differences between groups was determined with Chi Square with p <0.05 considered significant.

Results: During the study period there were 3191 unique feedback requests. The overall response rate was 62%. The faculty response rate was 66%, senior residents (PGY 3-7) 59%, and junior residents (PGY 1-2) 60%. Separated by respondents, general feedback was given by 60% of faculty, 72% of senior residents, and 68% of junior residents; the difference between groups was not significant. Specific feedback was given by 16% of faculty, 8% of senior residents, and 17% of junior residents (p < 0.05 between faculty and all residents). Faculty provided “good” feedback 16% of the time, compared to 8% of senior resident feedback and 17% of junior resident feedback (p < 0.05 between faculty and senior residents). “Mediocre” feedback from faculty was 13% of comments while 9% of senior resident and 7% of junior resident feedback met the same criteria (p <0.05 between all groups).  “Bad” feedback comprised 67% of total feedback, including 60% of faculty feedback, 72% of senior resident feedback, and 68% of junior resident feedback (p < 0.05 between all groups).

Conclusion: Using a novel, web-based feedback system we found the majority of feedback provided to medical students during their core surgery clerkship was poor quality, consisting primarily of general and encouraging comments. This represents an opportunity for system development and surgeon education regarding optimal feedback techniques.

 

75.09 The Effect of a Resident Driven Educational Workshop on Medical Student Transition to Clinical Medicine

Posted on January 26, 2017

R. F. Brown1, M. Shen1, A. Charles1  1University Of North Carolina,Chapel Hill, NC, USA

Introduction: The transition from pre-clinical years to full time clinical studies is a difficult and often anxiety-inducing experience for medical students.  Our aim was to assess the efficacy of a resident driven two-hour workshop in preparing pre-clinical medical students to start clinical rotations. 

Methods: A prospective survey measuring comfort (1=least to 5=most comfortable) and anxiety (1=least to 5=most anxious) levels was administered to a convenience sample of pre-clinical medical students prior to transitioning to clinical rotations.  The same survey was administered to students following their voluntary participation in a resident driven transitions workshop. Pre-workshop and post-workshop scores were averaged and compared using simple T-test.

Results: The response rate for the pre-course survey was 93% (65/70) for all students and 95% (42/44) for the post-course test, administered only to students who participated.  There were no differences in age, gender, or race between the two groups of surveyed students.  Students reported a significant increase in overall comfort with daily hospital tasks after participation in the resident workshop (3.7±0.89) when compared to all students prior to the workshop (3.25±1.10 (p<0.0001), with statistically significant improvement in 13/19 sections (p<0.0001 for all) and improvement nearing significance in 3 additional section (p<0.07) (See Figure 1).  Students also reported decreased overall anxiety after workshop participation (3.09±1.15 vs. 2.82±1.05, p=0.0001), with significant decrease in anxiety in 2/10 sections included in the survey (p=0.02, 0.008) and nearing significance in one additional section (p=0.061).

Conclusions: Students reported increased comfort and decreased anxiety after participation in a resident driven pre-clinical workshop.  These data suggest that hands-on experience with pre-rounding exercises as well as interaction with residents prior to starting clinical rotations can provide a potential benefit to medical students.

75.08 Quality of Medical Student Documentation Based on Evaluation and Management Code in a Surgical Clinic

Posted on January 26, 2017

R. Howard1, R. Reddy1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:
Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. As such, significant time is dedicated to teaching documentation skills to medical students, including writing a history, physical examination, and plan. However, students receive little to no education regarding documentation compliance with evaluation and management (E/M) coding that is applied to all patient encounters in the United States. The following study aims to assess the coding compliance of medical student documentation.

Methods:
One hundred medical records at a thoracic surgery clinic in an academic medical center were retrospectively audited that contained documentation by both the attending surgeon and a third year medical student for the same patient encounter. Faculty documentation was composed by one faculty member, and student documentation by 47 students. Records were then de-identified and assigned a level of service by trained, expert coders using a Current Procedural Terminology (CPT) E/M code. Differences in CPT code were then compared between medical student and faculty documentation.

Results:
Of the 100 clinical encounters, 80 were new patient evaluations and 20 were postoperative visits. Medical student documentation was coded at the same level of service in 38 cases, a lower level of service in 53 cases, a higher level of service in one case, and an incorrect service in 8 cases (postoperative visits coded as new evaluations). Among new patient evaluations, student documentation was more likely to be coded at a lower level of service. For example, 93% of faculty documentation was coded as a Level 4 encounter compared to only 29% of student documentation. Reasons for lower CPT code were lack of detail in history of present illness (HPI) and insufficient number of systems in physical examination.

Conclusion:
When compared to faculty documentation, medical student documentation is coded at a lower level of service due to lack of detail in HPI and physical examination. Although students receive extensive teaching regarding documentation, these results reflect the need for education regarding E/M coding, which is integral to real world practice. Therefore, additional teaching on this topic is merited in medical education.
 

71.08 Humans vs. Pigs vs. Rats; Native TEG Distribution Indicates Limitations of Animal Models of TIC

Posted on January 26, 2017

P. J. Lawson1, H. B. Moore1,2, G. R. Stettler1,2, A. L. Slaughter1,2, A. W. Bacon1,2, M. Fragoso1,2, A. Banerjee1, E. E. Moore1,2  1University Of Colorado Denver,Aurora, CO, USA 2Denver Health Medical Center,Aurora, CO, USA

Introduction:
Thrombelastography (TEG) has been used increasingly to characterize the coagulation changes associated with traumatic injury and hemorrhagic shock. However, animal models developed to investigate trauma induced coagulopathy (TIC) have failed to produce objective excessive bleeding. In patients activated TEGs (rapid and kaolin) are less sensitive in detecting hypercoaguable states following injury compared to a non-activated (native) TEG. We hypothesize that a native TEG will demonstrate marked differences in humans compared to these experimental models, which explains the difficulties in reproducing a clinically relevant coagulopathy in animal models.

Methods:
Whole blood was collected from 134 healthy human volunteers, 25 swine and 64 Sprague Dawley rats prior to experimentation. Citrated Native TEG’s were run on each whole blood sample within 2 hours of blood draw. The R-Time(min), Angle(degrees), MA(mm), and LY30(%) were analyzed and contrasted between species with data represented as the median and 25th to 75th quartile range.  Difference between species was conducted with a Kruskall Wallis test with alpha adjusted with a Bonferroni correction for multiple comparison (alpha = 0.016).

Results:
R-Time (clot initiation) was 17.9 min (15.0-21.1) for humans, 5.7 (4.9-8.8) for pigs, and 5.2 (4.4-6) for rodents. Humans had longer R-Times than both pigs (p<0.0001) and rats (p<0.0001); pigs were not different from rats. Angle (fibrin cross-linking) was 28.0 degrees (21.4-40.3) for humans, 71.7 (64.3-75.6) for pigs, and 61.8 (56.8-66.7) for rats. Humans had reduced Angle than both pigs (p<0.0001) and rats (p<0.0001); pigs were not different from rats. MA (clot strength) was 51.5 mm (47.4-55.0) for humans, 72.5 (70.4-75.5) for pigs, and 66.5 (56.5-68.6) for rats. Humans had reduced MA than both pigs (p<0.0001) and rats (p<0.0001); pigs were not different from rats. LY30 (fibrinolysis) was 1.2 % (0.6-2.2) for humans, 3.3 (1.9-4.3) for pigs, and 0.5 (0.1-1.2) for rats. Humans had a lesser LY30 than pigs (p=0.0006) and a greater LY30 than rats (p=0.0005), and pigs had a greater LY30 than rats (p<0.0001).

Conclusion:
Humans, swine, and rodents have distinctly different coagulation profiles when evaluated by native TEG. Animals are hypercoaguable with rapid clotting times and clots strengths nearly 50% stronger than humans. These coagulation differences indicate the limitations of previous models of TIC in producing coagulation abnormalities associated with increased bleeding. The inherent hypercoaguable baseline tendencies of these animals may result in subclinical biochemical changes that are not detected by conventional TEG and should be taken into consideration when extrapolated to clinical medicine.

71.02 Identifying Lost Surgical Needles with Visible and Near Infrared Fluorescent Light Emitting Coating

Posted on January 26, 2017

E. P. Ward1, J. Yang3, J. Delong1, J. Wang2, N. Mendez4, C. Barback5, S. Horgan1, W. Trogler3, A. Kummel3, S. Blair1  1University Of California – San Diego,General Surgery,San Diego, CA, USA 2University Of California – San Diego,Nanoengineering,San Diego, CA, USA 3University Of California – San Diego,Chemistry,San Diego, CA, USA 4University Of California – San Diego,Material Science,San Diego, CA, USA 5University Of California – San Diego,Radiology,San Diego, CA, USA

Introduction: The consequences of retained foreign bodies (RFB) are significant for all types of medical procedures, but in laparoscopic surgery, RFB such as lost surgical needles may cause a minimally invasive surgery (MIS) to be converted to an open surgery. MIS relies on an endoscopically placed camera for navigation and visual localization of a small item, such as a needle, can be daunting and time consuming. A dual-purpose film to coat surgical needles was developed to augment localization of needles under UV (black light) for open procedures and near infrared (NIR) light for MIS cases using specialized fluorescent laparoscopes.

Methods: Epoxy was used as the matrix for dansyl chloride (DC) and indocyanine green (ICG) as visible and NIR labels, respectively, in a single film.  The needles were coated via dip coating with methanol cosolvent and subsequently cured at room temperature to form a clear polymer film with tunable thickness ranging from 10 to 30 um. With UV excitation at 390 nm, DC emits green fluorescence at 520 nm. With 980 nm NIR excitation, ICG dye emits NIR light above 1000 nm visible with specialized laparoscopes. IACUC approved open and laparoscopic surgeries were simulated in New Zealand white rabbits. In the laparoscopic setting, 26 needles were searched for with a standard camera by a surgeon and 26 with an NIR sensitive laparoscope. The surgeon was blinded to needle location. In the open laparotomy setting, 26 needles were searched for with standard light and 26 were searched for with a UV light. Control needles not located within the maximum 300 s were searched with the assistance of the corresponding NIR or UV light. Time to identification was evaluated for statistical significance, p<.05. 

Results:All 52 dual dye coated needles searched utilizing the NIR camera (n=26) or UV light (n=26) were located within 300 s. 9 needles in both control settings were unable to be located within 300 s (p=0.0006). The mean time to locate control needles in the open surgery and laparoscopic surgery was statistically 2-3x longer than the time to localization utilizing the dye as an adjunct (p=.0027 for open, p<.001 for laparoscopic, Table 1). Overall the dual dye resulted in greater reducuction in time required to locate the needles in laparoscopic surgery compared to open surgery (p=.0006).

Conclusion:The incorporation of a dual-dye coating on surgical needles shows potential to improve the efficiency of locating RFB and may minimize the need to convert a MIS procedure to an open surgery.  Although a benefit was quantified for open surgery the greatest benefit was observed in MIS. Dual-dye coating of surgical needles has potential to decrease the time to localize lost surgical needles and may reduce the risk of RFB.

69.05 Self–inflicted Gunshot Wounds: Readmission Rates

Posted on January 26, 2017

C. M. Rajasingh1, L. Tennakoon1, K. L. Staudenmayer1  1Stanford University,Department Of Surgery,Palo Alto, CA, USA

Introduction:  Self-inflicted gunshot wounds (SI-GSW) are often fatal, but those who survive get hospitalized for their injuries. What happens to these survivors after the initial hospitalization is not known. We hypothesized that patients who survive a SI-GSW are frequently readmitted. We also hypothesized that rates would be higher than those admitted for other mechanisms of deliberate self-harm (DSH).

Methods:  This is a retrospective cohort analysis of hospital visits using the National Readmission Database (NRD) from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, 2013. The NRD is a new nationally representative sample of inpatient hospitalizations in the U.S. with an identifier that allows for linkage across hospitalizations.  We included patients with any diagnosis indicating deliberate self-harm (DSH) as coded by International Statistical Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes. This group was divided into those who had SI-GSW as their mechanism for self-harm and those who did not. In order to have 6-month follow-up data, we excluded patients discharged in the second half of the calendar year. Patients who did not survive their initial hospitalization were excluded. Weighted numbers are reported below.

Results: A total of 492 patients were admitted for SI-GSW between January and June 2013. The majority were male (N=396, 81%) and 34% (N=167) were ages 22-35. Of these patients, 156 (32%) experienced at least one readmission in 2013. The mean time to the first readmission was 72 days. The top three diagnosis group reasons for readmissions included Mental Health (31%), Injury or Poisoning (15%), and Musculoskeletal (11%).  Readmissions for self-harm were low (<5%; small numbers not reportable per HCUP publishing restrictions). When compared to those admitted for DSH by non-firearm-related mechanisms, readmission rates were not statistically different (SI-GSW vs. other DSH 32% vs. 31%, p=0.70). However, readmissions for repeat self-harm were lower for the SI-GSW cohort (SI-GSW vs. other DSH <5% vs. 8%, p<0.001). In multivariate analysis controlling for patient and injury characteristics, SI-GSW was associated with a lower odds ratio for repeat self-harm admissions compared to other forms of DSH (OR 0.28, p=0.015).

Conclusion: Readmissions after survival for SI-GSW are frequent, indicating that estimates of the burden of survival can be underestimated if only focused on the initial hospitalization. To our knowledge, this is the first study to describe national readmission rates after SI-GSW. Furthermore, there are differences in readmission rates for SI-GSW vs. other forms of DSH. Overall readmission rates are the same for both groups, but the odds ratio for repeat self-harm admissions is 70% lower for the SI-GSW group even after controlling for severity of injury. This suggests opportunities for prevention and follow-up may differ between the two groups. 

 

68.05 Transplant Offers Survival Benefit Over Resection for Patients with HCC and Preserved Liver Function

Posted on January 26, 2017

J. B. Liu1,2, T. B. Baker4, N. Suss3, M. S. Talamonti2,3, K. K. Roggin2, D. J. Winchester2,3, M. S. Baker2,3  1American College Of Surgeons,Chicago, IL, USA 2University Of Chicago,Chicago, IL, USA 3Northshore University Health System,Evanston, IL, USA 4Northwestern University,Chicago, IL, USA

Introduction:
Prior studies from large national datasets comparing transplantation and resection for hepatocellular cancer (HCC) have not appropriately controlled for liver function. Previous multi-institutional series comparing transplantation and resection have included small numbers of patients with preserved liver function while also including those with decompensated cirrhosis. The benefit of transplantation relative to resection in patients with preserved liver function and potentially resectable HCC continues to be subject of considerable debate. 

Methods:
We evaluated patients from the National Cancer Data Base (NCDB) undergoing treatment for HCC between 2010 and 2013 with calculated MELD scores <11. Patients undergoing resection were 1:1 propensity-matched to patients undergoing liver transplantation based on age, gender, comorbidity burden, tumor size, tumor multiplicity, pathologic stage, margin status and MELD score. Logistic regression models with robust standard errors were constructed to examine 30- and 90-day mortality. Unadjusted and adjusted survival analyses were conducted using Kaplan-Meier and shared frailty models.

Results:
2,463 patients underwent operative management for HCC. Patients undergoing resection were more likely to have positive resection margins than those undergoing transplantation (7.0% vs. 0.3%, p <0.0001). After propensity matching, 854 patients were included in our study: 427 underwent resection and 427 underwent transplantation. Rates of 30- (1.9% vs 1.9%, p = 1.00) and 90-day mortality (3.3% vs 3.0%, p = 0.85) were identical between matched cohorts. Median follow-up was 551 days for those undergoing resection and 607 days for those undergoing transplantation. Patients undergoing resection demonstrated lower rates of overall survival relative to those undergoing transplantation in unadjusted analysis (median overall survival 39% vs not reached, p < 0.0001, log-rank test)  and an increased risk of death in shared frailty models (hazard ratio 2.21 [95% confidence interval 1.54-3.17]).

Conclusion:
Individualized care models are the cornerstone of treatment pathways for patients with HCC. In the subset of those with preserved liver function, there is active controversy as to whether resection or transplant offer superior overall survival rates for these patients. This propensity matched analysis of a large national database demonstrates a clear survival advantage for transplantation. Further prospective randomized clinical trials are needed to validate these findings.
 

58.03 A Novel Model of Aortic Aneurysm Rupture

Posted on January 26, 2017

A. Z. Fashandi1, M. D. Salmon1, R. B. Hawkins1, M. Spinosa1, G. Lu1, G. Su1, G. Ailawadi1, G. R. Upchurch1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA

Introduction:  Given the relative unknown biologic antecedents that occur prior to aortic aneurysm rupture in humans, the purpose of this study was to establish a reproducible murine model of aortic aneurysm (AA) rupture.

Methods:  Seven-week-old apolipoprotein E deficient (ApoE-/-) mice were fed a high fat diet for 4 weeks and subcutaneous osmotic infusion pumps containing Angiotensin II (ATII) were then implanted. ATII was delivered continuously for 4 weeks at either 1000ng/kg/min (n=25) or 2000ng/kg/min (n=29). A third group of mice (n=14) was given ATII at 2000ng/kg/min and 0.2% β-aminopropionitrile (BAPN) dissolved in the drinking water. Surviving mice were euthanized 28 days after osmotic infusion pump placement and aortic diameters were measured. All animals that died prior to 28 days underwent autopsy to determine cause of death. Survival was analyzed by Kaplan-Meier while rates of aortic rupture and aneurysm formation were analyzed with Chi-squared or Fisher’s exact test, where appropriate. Statistical analysis was performed with GraphPad Prism 7.0 and significance was set at a of 0.05.  

Results: Survival was significantly different among the three groups with 80% survival at 28 days in the 1000ng/kg/min group, 52% in the 2000ng/kg/min group, and only 14% survival in the ATII/ BAPN group (p=0.0001; Figure 1). Unadjusted comparisons between each group were also significantly different (p<0.05). Rupture rates were statistically different among groups (8% vs 38% vs 79%, p<0.0001) and were again different on unadjusted comparison between groups (p<0.03). Incidence of abdominal AA formation were 48%, 55% and 93% in the three experimental groups and there were statistically significant differences between the ATII/ BAPN group and both the 1000ng/kg/min ATII and the 2000ng/kg/min ATII groups (p=0.006 and p=0.0165, respectively). Finally, rates of ascending thoracic AA formation were 12%, 52% and 79% in the three experimental groups with statistically significant differences between the 1000ng/kg/min ATII group and both the 2000ng/kg/min ATII and the ATII/ BAPN groups (p=0.0033 and p<0.0001, respectively). 

Conclusion: In this study, a reproducible model of aortic rupture was developed with a high incidence of both abdominal and thoracic aortic aneurysm formation. This model should enable further studies to expand on research in aortic aneurysms and the pathogenesis of aortic rupture, as well as targeted strategies to prevent human aortic aneurysm rupture. 

 

57.19 Surgery’s Role in Global Public Health is Invisible in MPH Curricula

Posted on January 26, 2017

W. S. Hercule1, A. L. Kushner3, S. M. Wren2  1Stanford University,Palo Alto, CA, USA 2Stanford University School Of Medicine,General Surgery,Stanford, CALIFORNIA, USA 3Surgeons OverSeas,New York, NY, USA

Introduction:
Global health initiatives have traditionally focused on communicable disease (CD) treatment and management. Worldwide health gains are now calling into focus the role that non-communicable diseases (NCD) have on premature, under age 60, deaths.  NCD such as cancer, cardiovascular disease, injury, and diabetes often require surgery for diagnosis, treatment, or palliation. A Masters of Public Health (MPH) degree focuses on preparation for a public health career. This study examines MPH curricula for course offerings in CD, NCD, and surgery to see if education has kept pace with the increasing role of NCD and the need for surgical care.

Methods:
The top 10 US News and World Reports (2016) ranked MPH programs’ online curricula offerings were key word searched for CD, NCD, and surgery (table 1). Search terms included the most common CD causes of death (6) and prevalent NCDs (14). Courses were categorized (CD or NCD). Surgery related courses were highlighted. Summary data were reported only for institutions with complete course listings. All 10 programs websites and curricula were searched for the key words (surgery or surgical) in a separate analysis.

Results:
Of the 10 programs 4 (UMN, UC-Berkley, Harvard, UW) had incomplete course listings or descriptions and 6 (JHSPH, UNC, UMICH, Columbia, Emory, BU) had complete listings. Five of six institutions offered more courses in NCD than CD. On average there were 32.0 NCD courses and 26.7 CD courses. There was significant variability in total number of courses queried from a low of 29 (UNC) to 112(JHSPH). Overall there were 160 courses on CD and 192 on NCDs between the programs. Only 2 institutions (JHSPH and UW) had course content on surgery (2 of 112 total JHSPH courses). Website searches of the other 8 programs’ materials could not identify the words “surgery” or “surgical” even when course title words such as cancer, injury, and trauma were key content areas for discussing the role of surgery. 

Conclusion:
Top tier US MPH degree programs have mirrored the emergence of NCD impact on global health while maintaining CD education. The role of surgery in public health, especially in NCD, is still sorely lacking even in institutions with global surgical leaders. Surgery is still not featured in searchable online courses and curricula in all but 2 of these institutions. We recognize that there are limitations to using online searches to examine content since full course syllabi cannot be assessed and surgical content may have been missed. Even with this limitation it is still clear that surgery as a key content area has not yet reached core or elective curricula in MPH programs and remains the “neglected stepchild of public health.”
 

57.14 The Effect of Surgical Boot Camp on Medical Student Confidence and Clinical Reasoning

Posted on January 26, 2017

S. Liu1, J. Unkart1, D. Hemming1, B. Sandler1, G. Jacobsen1, J. Baumgartner1  1University Of California – San Diego,Surgery,San Diego, CA, USA 1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:  An internship in surgery requires clinical communication and decision-making skills not adequately covered in the standard medical curriculum. This study investigates the immediate and ongoing effect of a month long course for 4th year medical students entering surgical residencies taught by a combination of attendings and residents. 

Methods:  This is a prospective study on the effect of a 4 week elective course (“Boot Camp”) designed to prepare medical students for a surgical internship. The course is modeled after the American College of Surgeons Resident Prep Curriculum created for 4th year medical students entering surgical residency. The curriculum included an average of 6 hours of course work per day divided into didactics, skills labs, and operative anatomy (cadaver and porcine) sessions taught by surgical attendings and residents. Students were evaluated for their confidence, ability to triage pages, ability to decide when to call for senior resident or attending backup when on call, and ability to effectively selective information to signout to a colleague. This was done before, after, and at 3 months follow-up.

Results: A total of 9 students were enrolled in the course (4 general surgery, 2 ENT surgery, 2 neurosurgery, and 1 plastic surgery). The progression of confidence on various subjects is seen in the graph below from a scale of 0-100% confident. There was an average overall increase in confidence which rose from 49% ± 6.8% at baseline to 65.7% ± 7.9% immediately at the end of boot camp (P<0.001). However, the average change from baseline at 3 months (54.1% ± 11.6%) was not significant (P=0.288). Test scores on exams designed to assess student ability to prioritize clinical acuity and identify important clinical information during signout did not show significant improvement at either time point. Tests of decisions to call a senior resident or attending backup found rates of over-calling increased from 3.3% to 8.3% and to 10.6% (P=0.025) at the three time points. The rates of under-calling  did not change significantly (10% to 12% to 8.8%). 

Conclusion: A month long surgical boot camp for 4th year medical students had a significant effect in boosting immediate confidence in their clinical abilities and preparedness for internship . The tendency to overcall senior backup increased at follow-up in concordance with decreased confidence. These findings suggest the need for additional intervention after the boot camp in order to achieve sustained effects in medical student confidence and clinical reasoning before internship. 

 

57.12 Promoting Clinician Engagement in Tobacco Cessation: A Pilot Study

Posted on January 26, 2017

J. Pollichemi2,3, M. Masika2,3, O. Lucas2,3, B. Bigham1,2, K. Attwood2,3, M. Reid2,3, M. Mahoney2,3, C. Nwogu2,3  1Howard University College Of Medicine,Washington, DC, USA 2Roswell Park Cancer Institute,Buffalo, NY, USA 3State University Of New York At Buffalo,Buffalo, NY, USA

Introduction:
Smoking cessation, regardless of a patient’s prognosis, is important for improving health, quality of life, and reducing comorbidities. Therefore, it is important that clinicians provide smoking cessation services. This study assesses the effectiveness of a 1-hour educational interventional program on clinicians providing smoking cessation services in the thoracic clinic at a comprehensive cancer center.

Methods:
New patients that were current smokers with cancer were identified by a retrospective chart review. In order to establish current clinician behavior, no action was taken to alter practices six weeks prior to the educational intervention. Patients seen in the thoracic clinic during this time were assigned to the ‘before cohort’. Patients seen six weeks after the intervention were assigned to the ‘after cohort’. The cohorts were compared by assessing the number of clinicians that provided the following smoking cessation services: advising patients to quit, counseling patients, and offering pharmacotherapy.

Results:

A total of 257 charts were reviewed: 141 belonged to the ‘before cohort’ and 116 belonged to the ‘after cohort’. Of the ‘before cohort’, 27 were current smokers, 69 were former smokers, 28 never smoked and 17 were undocumented. Of the ‘after cohort’, 23 were current smokers, 61 were former smokers, 27 never smoked and 5 were undocumented. The demographics, comorbidities, and smoking habits did not differ significantly between the two cohorts. There was a trend towards an increase in clinicians providing smoking cessation services after the educational session but it did not reach statistical significance (Figure 1).

Conclusion:

These results indicate that barriers exist for providing smoking cessation services. Perhaps a larger sample size is needed to identify a smaller effect that this educational program had on clinician practices. It is also possible that ongoing education programs are necessary to have an appreciable effect on clinician behavior.

 

[Figure 1:  Smoking cessation services in the pre-intervention versus post-intervention cohorts]

57.11 Defining Mistreatment On Surgery Clerkships: A Medical Student-Generated Definition

Posted on January 26, 2017

E. Brandford1, D. Hoang1, B. Hasty1, E. Shipper1, S. Merrell1, D. Lin1, J. Lau1  1Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:

Mistreatment has many negative effects on medical students including increased burnout, post-traumatic stress, depressive symptoms, drinking for escape, and decreased confidence in clinical skills. Mistreatment is reported at high rates during surgery clerkships, and may result in a decreased interest in pursuing a surgical residency. Despite the consensus that mistreatment is a problem that needs to be addressed, there exists no uniform definition of medical student mistreatment. Definitions used by medical institutions typically includes a small number of specific acts but are not necessarily based on medical student experiences. Without first defining mistreatment, we cannot develop interventions to prevent it. Our purpose was to characterize student generated definition(s) of mistreatment.

Methods:
An anonymous survey was distributed to medical students during both the first and last didactic session of their 8-week required surgery clerkship. Open ended survey questions asked students to define mistreatment generally, within the context of a surgery rotation, and to give examples of medical student mistreatment (real or hypothetical). Survey responses were qualitatively analyzed using content and thematic analysis to determine the components of mistreatment.

Results:
Between January 2014 and June 2016 a total of 219 medical students participated in the general surgery clerkship. 197 (90%) of students completed the pre-clerkship survey, and 183 (84%) completed the post clerkship survey, generating a total of 380 responses. Preliminary data analysis suggests that the features of mistreatment, as defined by medical students, can be described by four major categories: 1) perceived intent of the educator, 2) acts of mistreatment, 3) outcome of the action for the student and the educational environment, and 4) setting in which mistreatment takes place. The acts of mistreatment in the medical student generated definitions included examples not represented by traditional definitions of mistreatment, which are often limited to verbal abuse, physical abuse, discrimination and embarrassment. In addition, medical student definitions included subtler actions such as neglect and exclusion from learning.

Conclusion:
Our qualitative analysis demonstrates that a wide breadth of factors constitute mistreatment in surgical clerkships that is not captured by official definitions often used by medical institutions. While traditional acts of mistreatment were represented, student generated definitions also emphasized the context in which those actions took place, including the setting, the intent of the educator, and the final impact on the student. This delineation of mistreatment paves the way for the development of interventions to target the expanded range of actions, intents, and outcomes that students report as constituting mistreatment.
 

57.10 Who’s Reading All Those Tweets, Anyway? Diversity in the #ASC2016 Audience

Posted on January 26, 2017

H. J. Logghe1, J. T. Adler2, M. A. Boeck3, S. B. Bryczkowski4, A. M. Ibrahim5, A. N. Kothari6, N. Nagarajan8, S. Scarlet1, L. V. Selby9, C. D. Jones7  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2Massachusetts General Hospital,Boston, MA, USA 3New York Presbyterian Hospital,Columbia,New York, NY, USA 4Rutgers New Jersey Medical School,Newark, NJ, USA 5University Of Michigan,Ann Arbor, MI, USA 6Loyola University Medical Center,Hines, IL, USA 7Johns Hopkins University School Of Medicine,Baltimore, MD, USA 8Brigham And Women’s Hospital,Boston, MA, USA 9University Of Colorado Denver,Aurora, CO, USA

Introduction:  Twitter coverage of professional meetings is a novel method used by attendees to enhance the conference experience and to amplify professional education beyond the traditional audience. While previous articles have quantified the number of tweets, participants, and impressions during medical conferences, little is known about the audience reached by these tweets. The current study seeks to evaluate the audience reached by the 2016 Academic Surgical Congress (ASC).

Methods:  Tweets which included the #ASC2016 hashtag were prospectively gathered using the Symplur Healthcare Hashtag Project. The top ten tweeters were determined by the number of tweets posted from 1 day before to 1 day after the conference. Follower profiles of the top ten tweeters were obtained from SimplyMeasured and analyzed for geographic location (as time zone) and profile text. Differences in location were analyzed to determine the geographic diversity of conference Twitter followers. Keyword analysis was performed to compare the profiles of followers who self-reported as surgeons to those who did not.

Results: There were 39,090 followers of the top ten tweeters with 21,880 unique followers, demonstrating significant overlap in individual followers. Among those users reporting time zones (12,077; 55%), 23 of the 24 standard time zones are represented. On review of individual profiles, 18% of followers contained a reference to surgery; 27% contained a reference to medicine or health but not surgery. Profile keywords were substantially different between those who did and did not identify as surgeons.

Conclusion: To our knowledge this study is the first analysis of Twitter users following the tweeters from a health care conference rather than of those making the posts. Only 18% of followers’ profiles contained a reference to surgery, suggesting the #ASC2016 readers included many users outside the surgical field. Furthermore, follower time zone distribution was diverse, representing followers from around the world. These findings suggest conference tweeting is an effective method to disseminate conference programming beyond the traditional audience to those outside the surgical field as well as to those unable to physically attend.

 

57.09 Evaluation of Video Game Skill for Future Training Modalities in Robotic-Assisted Surgery

Posted on January 26, 2017

K. Oh1, A. Esposito1, N. L. Owen-Simon1, S. Dachert1, J. Kaplan1, A. Kamenko1, S. Shipman1, J. Rehrig1, K. Walters1, K. Ray1, E. Buchanan1, A. Reese1, A. Harbin1, B. Waldorf1, D. Eun1  1Temple University School Of Medicine,Department Of Urology,Philadelphia, PA, USA

Introduction:  As robotic-assisted surgery (RAS) is adopted across a variety of surgical fields, the question of which skill sets predict RAS proficiency is increasingly relevant.  We investigate the relationship between video game proficiency and surgical robot proficiency.

Methods: 116 undergraduate and pre-clinical medical students took a diagnostic exam on the Nintendo Wii system, completing three attempts of five levels of “Super Monkey Ball: Banana Blitz”. Composite scores were calculated based on task completion and time to completion. Subjects then performed 5 attempts each of peg transfer, pattern cutting, and running suture on the Da Vinci Xi Surgical Robot (Da Vinci). Time to completion and accuracy of tasks were recorded.  Participants with prior experience in either video game or Da Vinci were excluded.  

Results: Preliminary results from 27 subjects are described.  The distribution of video game final scores ranged from 681.42 to 11016.43 with a mean of 4553.38 (SD=2885.7).  On Da Vinci, timed tasks included peg transfer (mean= 2:10.7 min, SD = 40.6 sec), precision cutting (mean= 3:20.56 min, SD = 73.2 sec), and running suture (mean= 5:51.9 min, SD = 60.0 sec). 

 

Correlations were calculated across trials controlling for random intercepts by participant.  A significant inverse relationship existed between final composite video game score and time to completion of running suture, r =-.33, p < 0.01.  A similar trend occurred in the remaining timed tasks, precision cutting and peg transfer, with trends approaching significance at r = -.23, p = 0.08 and r = -.23, p = 0.085. 

Conclusion: Video game skill and RAS skill have a significant correlation. This study is the largest prospective study to date investigating skills predicting RAS performance. As use of RAS is increasingly prominent, it is essential to identify skill sets predictive of proficiency on this platform to develop future surgical teaching strategies and education curricula.
 

57.08 Postoperative Conversations with Family: How Effectively Do We Communicate?

Posted on January 26, 2017

M. R. Thayer1, C. S. Young1, M. E. Rosenbaum2, M. R. Kapadia3  1University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA 2University Of Iowa,Department Of Family Medicine,Iowa City, IA, USA 3University Of Iowa,Department Of Surgery,Iowa City, IA, USA

Introduction:
Families often play an essential role in the postoperative care of surgical patients. The conversation in the immediate postoperative period provides an opportunity for surgeons to communicate with families regarding patient status and care. Empirical investigations of postoperative communication practices with families have been limited to surgeon self-report, and there is a lack of primary observational data. The aim of this study was to broaden understanding of surgeon-family postoperative interactions through analysis of conversation content and structure.

Methods:
Conversations between surgeons and families in the immediate postoperative period were audio-recorded. The recordings were transcribed, coded, and analyzed using the QSR NVivo 10 program. An iterative process was utilized to identify content and themes of these conversations. Using a modified numerical EPSCALE, conversations were evaluated regarding general communication skills in explanation and planning (scored 0-3, with 0 indicating poor performance and 3 indicating excellent performance). 

Results:
Postoperative conversations from 25 surgical cases were recorded and analyzed (N=10 surgeons). The majority of cases required inpatient admission (84%) and included bariatric, colorectal, surgical oncology, and minimally invasive procedures.  The average conversation length was 4 minutes (range 1-7), and family members present ranged from 1 to 3. Subject matter pertaining to what happened during surgery, surgical outcome, and short-term postoperative course were addressed in nearly every discussion (100%, 96%, 92%, respectively). Surgeons provided opportunities for family inquiry in 87% of encounters, primarily at the completion of, rather than during, the conversation. Family members asked an average of 4 questions per conversation, generally related to the short-term postoperative course (30%), what happened during surgery (25%), and logistics on visiting the patient (16%). While postoperative conversations often included organized explanation, opportunities for family contribution, and chunking/checking, they differed from other information-sharing conversations in not typically incorporating starting point assessment (2/25 cases) and explicitly checking for family understanding (3/25 cases).

Conclusion:
This study presented an initial assessment of the contextual and structural patterns of postoperative conversations with families. It was demonstrated that similar content areas are addressed in these conversations. However, surgeons often do not employ many of the recommended communication skills for effective explanation and planning. This suggests that postoperative conversations are conceivably different from other information-sharing interactions. These findings have the potential to contribute to the development of surgical educational training materials.

57.07 A Comparison Of Parental Leave Policies For Academic Surgeons Across The United States

Posted on January 26, 2017

D. S. Itum1, S. C. Oltmann1, M. A. Choti1, H. G. Piper1  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction: Parent-child bonding during the earliest months of life provides significant health benefits to both child and parent. This frequently requires a dedicated parental leave with time away from full-time employment. Recently, two prominent surgical professional organizations (American College of Surgeons and Association of Women Surgeons) have endorsed formal parental leave policies. However, it is unclear whether the majority of surgeons at academic centers have access to formal parental leave. Family Medical Leave Act (FMLA) is an unpaid leave, and does not address additional job responsibilities that must be made up after returning to work, nor the financial burden of unpaid leave.  It is unclear if a paid, protected parental leave is offered across academic medical centers. The aim of this project was to investigate the current parental leave policies at the top 50 academic medical centers in the United States to determine trends and outliers among institutions.

Methods: The 2015 US World News report identified the top 50 academic medical centers within the United States.  Each institutional website was reviewed to determine the most current, publically available human resource policies with respect to parental leave. “Paid leave” was defined as a protected, paid leave offered by an institution without the mandated use of sick, vacation, or other personal time off. 

Results: Of the 50 programs, 30 (60%) are private and 20 (40%) are public. 13 (26%) institutions are located in the Northeast, 13 (26%) in the South, 10 (20%) in the Midwest and 14 (28%) in the West.  9 (18%) are located within states with a state-mandated paid parental leave policy. Thirty-five medical centers (70%) have a paid institutional parental leave. Offering of a paid parental leave at private versus public institutions (73% vs. 65%, p= .55), or based on region (Northeast = 77%; South = 69%; Midwest = 50%; West = 79%; p=.44) did not differ.  Availability of paid institutional parental leave differed based on medical center ranking (top third = 93.8%; middle third = 47.1%; bottom third = 70.6%; p=0.01).

Paid leave was further stratified by duration (none vs. £ 6 weeks vs. > 6 weeks). Private institutions were more likely to offer longer paid leaves (> 6 weeks) than public institutions (57% vs. 20%; p=0.02). No difference in duration of paid leave was noted based on region (p=0.81).

Conclusion: One third of top academic centers do not offer a paid parental leave policy. Private institutions offer longer leaves compared to public academic centers. Much work is still needed to ensure optimal access to paid parental leave after child birth and/or adoption. As surgical training often delays child rearing, it is critical that surgeons are at the forefront of supporting the further advancement of this benefit.
 

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