Faculty Bibliography

BACKGROUND:Underrepresented minorities in medicine (URiM) are disproportionally represented in surgery training programs. Rates of URiM applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiM disparities would persist into Surgical Critical Care (SCC) fellowship applicants, matriculants and graduates. METHODS:We performed a retrospective analysis of SCC applicants, matriculants and graduates from 2005-2020 using the Graduate Medical Education (GME) resident survey and analyzed applicant characteristics using the Surgical critical care and Acute care surgery Fellowship Application Service (SAFAS) from 2018-2020. The data were stratified by race/ethnicity and gender. Indicator variables were created for Asian, Hispanic, White and Black trainees. Yearly proportions for each race/ethnicity and gender categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and gender proportion as the dependent variables and year as the explanatory variable. RESULTS:From 2005-2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased. CONCLUSIONS:Disparities in URiM representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiM in SCC training are warranted. LEVEL OF EVIDENCE/METHODS:Level IV - Therapeutic/Care Management.

Importance/UNASSIGNED:The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number. Objective/UNASSIGNED:To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time. Design, Setting, and Participants/UNASSIGNED:In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021. Main Outcomes and Measures/UNASSIGNED:Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs. Results/UNASSIGNED:Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]). Conclusions and Relevance/UNASSIGNED:Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

BACKGROUND:Understanding how substance use is associated with severe crash injuries may inform emergency care preparedness. OBJECTIVES/OBJECTIVE:This study aims to assess the association of substance use and crash injury severity at all times of the day and during rush (6-9 AM; 3-7 PM) and non-rush-hours. Further, this study assesses the probabilities of occurrence of low acuity, emergent, and critical injuries associated with substance use. METHODS:Crash data were extracted from the 2019 National Emergency Medical Services Information System. The outcome variable was non-fatal crash injury, assessed on an ordinal scale: critical, emergent, low acuity. The predictor variable was the presence of substance use (alcohol or illicit drugs). Age, gender, injured part, revised trauma score, the location of the crash, the road user type, and the geographical region were included as potential confounders. Partially proportional ordinal logistic regression was used to assess the unadjusted and adjusted odds of critical and emergent injuries compared to low acuity injury. RESULTS:Substance use was associated with approximately two-fold adjusted odds of critical and emergent injuries compared to low acuity injury at all times of the day and during the rush and non-rush hours. Although the proportion of substance use was higher during the non-rush hour period, the interaction effect of rush hour and substance use resulted in higher odds of critical and emergent injuries compared to low acuity injury. CONCLUSION/CONCLUSIONS:Substance use is associated with increased odds of critical and emergent injury severity. Reducing substance use-related crash injuries may reduce adverse crash injuries.

BACKGROUND:In the United States, New York State's health care system experienced unprecedented stress as an early epicenter of the coronavirus disease 2019 (COVID-19) pandemic. This study aims to assess the level of hopelessness in New York State physicians working on the frontlines during the first wave of the COVID-19 outbreak. METHODS:A confidential online survey sent to New York State health care workers by the state health commissioner's office was used to gather demographic and hopelessness data as captured by a brief Hopelessness Scale. Adjusted linear regression models were used to assess the associations of physician age, sex, and number of triage decisions made, with level of hopelessness. RESULTS:In total, 1330 physicians were included, of whom 684 were male (51.4%). Their average age was 52.4 years (SD=12.7), with the majority of respondents aged 50 years and older (55.2%). Almost half of the physician respondents (46.3%) worked directly with COVID-19 patients, and 163 (12.3%) were involved in COVID-19-related triage decisions. On adjusted analysis, physicians aged 40 to 49 years had significantly higher levels of hopelessness compared with those aged 50 years or more (μ=0.441, SD=0.152, P=0.004). Those involved in 1 to 5 COVID-19-related triage decisions had a significantly lower mean hopelessness score (μ=-0.572, SD=0.208, P=0.006) compared with physicians involved in none of these decisions. CONCLUSION/CONCLUSIONS:Self-reported hopelessness was significantly higher among physicians aged 40 to 49 years and those who had not yet been involved in a life or death triage decision. Further work is needed to identify strategies to support physicians at high risk for adverse mental health outcomes during public health emergencies such as the COVID-19 pandemic.

INTRODUCTION/BACKGROUND:The COVID-19 Healthcare Personnel Study (CHPS) was designed to assess adverse short-term and long-term physical and mental health impacts of the coronavirus disease-2019 (COVID-19) pandemic on New York's physicians, nurse practitioners, and physician assistants. METHODS:Online population-based survey. Survey-weighted descriptive results, frequencies, proportions, and means, with 95% confidence intervals (95% CI). Odds ratios (ORs) for association. RESULTS:Over half (51.5%; 95% CI: 49.1, 54.0) of respondents worked directly with COVID-19 patients; 27.3% (95% CI: 22.5, 32.2) tested positive. The majority (57.6%; 95% CI: 55.2, 60.0) reported a negative impact on their mental health. Negative mental health was associated with COVID-19 symptoms (OR=1.7, 95% CI: 1.3, 2.1) and redeployment to unfamiliar functions (OR=1.3, 95% CI: 1.1, 1.6). CONCLUSIONS:A majority of New York health care providers treated COVID-19 patients and reported a negative impact on their mental health.

BACKGROUND:City-wide lockdowns and school closures have demonstrably impacted COVID-19 transmission. However, simulation studies have suggested an increased risk of COVID-19 related morbidity for older individuals inoculated by house-bound children. This study examines whether the March 2020 lockdown in New York City (NYC) was associated with higher COVID-19 hospitalization rates in neighborhoods with larger proportions of multigenerational households. METHODS:We obtained daily age-segmented COVID-19 hospitalization counts in each of 166 ZIP code tabulation areas (ZCTAs) in NYC. Using Bayesian Poisson regression models that account for spatiotemporal dependencies between ZCTAs, as well as socioeconomic risk factors, we conducted a difference-in-differences study amongst ZCTA-level hospitalization rates from February 23 to May 2, 2020. We compared ZCTAs in the lowest quartile of multigenerational housing to other quartiles before and after the lockdown. FINDINGS/RESULTS:Among individuals over 55 years, the lockdown was associated with higher COVID-19 hospitalization rates in ZCTAs with more multigenerational households. The greatest difference occurred three weeks after lockdown: Q2 vs. Q1: 54% increase (95% Bayesian credible intervals: 22-96%); Q3 vs. Q1: 48% (17-89%); Q4 vs. Q1: 66% (30-211%). After accounting for pandemic-related population shifts, a significant difference was observed only in Q4 ZCTAs: 37% (7-76%). INTERPRETATION/CONCLUSIONS:By increasing house-bound mixing across older and younger age groups, city-wide lockdown mandates imposed during the growth of COVID-19 cases may have inadvertently, but transiently, contributed to increased transmission in multigenerational households.

BACKGROUND:The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. METHODS:This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. RESULTS:Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. CONCLUSION/CONCLUSIONS:These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.

BACKGROUND:The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is controversial. We hypothesize that REBOA outcomes are improved in centers with high REBOA utilization. METHODS:We examined the Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry over a 5-year period (2014-2018). Resuscitative endovascular balloon occlusion of the aorta outcomes were analyzed by stratifying institutions into low-volume (<10), average-volume (11-30), and high-volume (>30) deployment centers. A multivariable model adjusting for volume group, mechanism of injury, signs of life, systolic blood pressure at initiation, operator level, device type, zone of placement, and hemodynamic response to aortic occlusion was created to analyze REBOA mortality and REBOA-related complications. RESULTS:Four hundred ninety-five REBOA placements were included. High-volume centers accounted for 63%, while low accounted for 13%. High-volume institutions were more likely to place a REBOA in the emergency department (81% vs. 63% low volume, p = 0.003), had a lower mean systolic blood pressure at insertion (53 ± 38 vs. 64 ± 40, p = 0.001), and more Zone I deployments (64% vs. 55%, p = 0.002). Median time from admission to REBOA placement was significantly less in patients treated at high-volume centers (15 [7-30] minutes vs. 35 [20-65] minutes, p = 0.001). Resuscitative endovascular balloon occlusion of the aorta mortality was significantly higher at low-volume centers (67% vs. 57%; adjusted odds ratio, 1.29; adj p = 0.040), while average- and high-volume centers were similar. Resuscitative endovascular balloon occlusion of the aorta complications were less frequent at high-/average-volume centers, but did not reach statistical significance (adj p = 0.784). CONCLUSION:Resuscitative endovascular balloon occlusion of the aorta survival is increased at high versus low utilization centers. Increased experience with REBOA may be associated with earlier deployment and subsequently improved patient outcomes. LEVEL OF EVIDENCE:Therapeutic/Care Management, level IV.