Diversity Is Needed Throughout All Aspects of the Editorial Peer Review Process for Surgery Journals—Reply

We read with great interest the Letter to the Editor by Wamalwa et al regarding our call to action to all surgery journal editors for diversity throughout the editorial and peer review process

Understanding Thoracic Outlet Syndrome

The diagnosis of thoracic outlet syndrome was once debated in the world of vascular surgery. Today, it is more understood and surprisingly less infrequent than once thought. Thoracic outlet syndrome (TOS) is composed of three types: neurogenic, venous, and arterial. Each type is in distinction to the others when considering patient presentation and diagnosis. Remarkable advances have been made in surgical approach, physical therapy, and rehabilitation of these patients. Dedicated centers of excellence with multidisciplinary teams have been developed and continue to lead the way in future research

Associations Between Career Satisfaction, Personal Life Factors, and Work-Life Integration Practices Among US Surgeons by Gender

Importance: Burnout among US surgeons is alarmingly high, particularly among women, and work-life integration conflicts contribute to career dissatisfaction. Objective: To evaluate associations between surgical career satisfaction and personal life factors such as time requirements for outside interests, household chores, and parenting responsibilities and to explore similarities and differences between men and women. Design, Setting, and Participants: This cross-sectional survey study of practicing US surgeons was conducted between June 4 and August 1, 2018. The 257-item online survey was sent to 25 748 fellows of the American College of Surgeons. A 31-item subanalysis was performed from August 13 to November 4, 2019. Main Outcomes and Measures: Degree of career satisfaction was measured on a 5-point Likert scale. Professional and personal life factors associated with career satisfaction were evaluated with gender-stratified multivariable proportional odds models. Results: Among 3807 respondents, 3166 self-identified as male (83%) and 639 (17%) as female. Fewer women reported career satisfaction (483 [77%] vs 2514 [82%]) and relatively more women reported problematic interruption of personal life owing to work (315 [50%] vs 1381 [45%]). A higher proportion of women reported being primarily responsible for meal preparation (282 [46%] vs 355 [12%]) and housekeeping (149 [24%] vs 161 [5%]). On multivariable analyses, factors independently associated with career satisfaction were generally similar between genders. Stronger collegial support of work-life integration efforts was significantly associated with higher career satisfaction for both genders (P < .001), although the odds ratio (OR) for women was higher than for men (OR, 4.52; 95% CI, 2.60-7.87 vs OR, 2.45; 95% CI, 1.88-3.21). For men and women, increasing age was significantly associated with higher career satisfaction (men: OR, 1.04; 95% CI, 1.03-1.05; P < .001; women: OR, 1.04; 95% CI, 1.02-1.06; P = .001), and insufficient time for family owing to work was associated with lower satisfaction (men: OR, 0.66; 95% CI, 0.49-0.90; P = 009; women: OR, 0.49; 95% CI, 0.30-0.81; P = .006). For women only, there was a significant association between primary responsibility for at least 1 household chore and lower career satisfaction (OR, 0.66; 95% CI, 0.45-0.98; P = .04). Conclusions and Relevance: In this study, although women had relatively lower surgical career satisfaction than men, the associations between career satisfaction and personal life factors were largely similar. Collegial support of work-life integration efforts appeared to be the most influential factor, particularly for women. Optimization of work-life integration may not only decrease physician burnout but also promote gender equity in surgery

Emerging New Approaches in Desensitization: Targeted Therapies for HLA Sensitization

There is an urgent need for therapeutic interventions for desensitization and antibody-mediated rejection (AMR) in sensitized patients with preformed or de novo donor-specific HLA antibodies (DSA). The risk of AMR and allograft loss in sensitized patients is increased due to preformed DSA detected at time of transplant or the reactivation of HLA memory after transplantation, causing acute and chronic AMR. Alternatively, de novo DSA that develops post-transplant due to inadequate immunosuppression and again may lead to acute and chronic AMR or even allograft loss. Circulating antibody, the final product of the humoral immune response, has been the primary target of desensitization and AMR treatment. However, in many cases these protocols fail to achieve efficient removal of all DSA and long-term outcomes of patients with persistent DSA are far worse when compared to non-sensitized patients. We believe that targeting multiple components of humoral immunity will lead to improved outcomes for such patients. In this review, we will briefly discuss conventional desensitization methods targeting antibody or B cell removal and then present a mechanistically designed desensitization regimen targeting plasma cells and the humoral response

Thrombalexin: use of a cytotopic anticoagulant to reduce thrombotic microangiopathy in a highly sensitized model of kidney transplantation

Early activation of coagulation is an important factor in the initiation of innate immunity, as characterized by thrombotic microangiopathy (TMA). In transplantation, systemic anti-coagulation is difficult due to bleeding. A novel 'cytotopic' agent, 'Thrombalexin', (TLN) combines a cell-membrane bound (mirystoyl tail) anti-thrombin (HLL peptide) which can be perfused directly to the donor organ or cells.. Thromboelastography (TEG) was used to measure time to clot formation (r-time) in both rhesus and human blood, comparing TLN vs. HLL (without cytotopic tail) vs. negative-control. Both TLN and HLL treated rhesus or human whole blood result in significantly prolonged r-time compared to kaolin controls. Only TLN-treated human endothelial cells (EC) and neonatal porcine islets (NPI) prolonged time to clot formation. Detection of membrane-bound TLN was confirmed by immunohistochemistry and FACS. In vivo, perfusion of a NHP kidney TLN-supplemented preservation solution in a sensitized model of transplantation demonstrated no evidence of TLN systemically. Histologically, TLN was shown to be present up to four days after transplantation. There was no platelet deposition and TMA severity, as well as microvascular injury scores (glomerulitis + peritubular capillaritis) were less in the TLN treated animals. Despite promising evidence of localized efficacy, no survival benefit was demonstrated. This article is protected by copyright. All rights reserved.</p

The Blue Ribbon Committee II Report and Recommendations on Surgical Education and Training in the United States: 2024.

OBJECTIVE: An expert panel made recommendations to optimize surgical education and training based on the effects of contemporary challenges. BACKGROUND: The inaugural Blue Ribbon Committee (BRC I) proposed sweeping recommendations for surgical education and training in 2004. In light of those findings, a second BRC (BRC II) was convened to make recommendations to optimize surgical training considering the current landscape in medical education. METHODS: BRC II was a panel of 67 experts selected on the basis of experience and leadership in surgical education and training. It was organized into subcommittees which met virtually over the course of a year. They developed recommendations, along with the Steering Committee, based on areas of focus and then presented them to the entire BRC II. The Delphi method was chosen to obtain consensus, defined as ≥80% agreement among the panel. Cronbach α was computed to assess the internal consistency of 3 Delphi rounds. RESULTS: Of the 50 recommendations, 31 obtained consensus in the following aspects of surgical training (# of consensus recommendation/# of proposed): Workforce (1/5); Medical Student Education (3/8); Work Life Integration (4/6); Resident Education (5/7); Goals, Structure, and Financing of Training (5/8); Education Support and Faculty Development (5/6); Research Training (7/9); and Educational Technology and Assessment (1/1). The internal consistency was good in Rounds 1 and 2 and acceptable in Round 3. CONCLUSIONS: BRC II used the Delphi approach to identify and recommend 31 priorities for surgical education in 2024. We advise establishing a multidisciplinary surgical educational group to oversee, monitor, and facilitate implementation of these recommendations

Practice Characteristics and Job Satisfaction of Private Practice and Academic Surgeons

IMPORTANCE: Private practice and academic surgery careers vary significantly in their daily routine, compensation schemes, and definition of productivity. Data are needed regarding the practice characteristics and job satisfaction of these career paths for surgeons and trainees to make informed career decisions and to identify modifiable factors that may be associated with the health of the surgical workforce. OBJECTIVE: To obtain and compare the differences in practice characteristics and career satisfaction measures between academic and private practice surgeons. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional survey performed from June 4 to August 1, 2018, an online survey accommodating smartphone, tablet, and desktop formats was distributed by email to 25 748 surgeons who were actively practicing fellows of the American College of Surgeons; had completed a general surgery residency or categorical fellowship in plastic, cardiothoracic, or vascular surgery; and had an active email address on file. MAIN OUTCOMES AND MEASURES: Demographic, training, and current practice characteristics were obtained, and satisfaction measures were measured on a 5-point Likert scale and compared by surgeon type. Nonresponse weights adjusted for respondent sex, age, and presence of subspecialty training between respondents and the total surveyed American College of Surgeons population. RESULTS: There were 3807 responses (15% response rate) from surgeons: 1735 academic surgeons (1390 men [80%]; median age, 53 years [interquartile range (IQR), 44-61 years]) and 1464 private practice surgeons (1276 men [87%]; median age, 56 years [IQR, 48-62 years]); 589 surgeons who reported being neither an academic surgeon nor a private practice surgeon and 19 surgeons who did not respond to questions on their practice type were excluded. Academic surgeons reported working a median of 59 hours weekly (IQR, 38-65 hours) compared with 57 hours weekly (IQR, 45-65 hours) for private practice surgeons. Academic surgeons reported more weekly hours performing nonclinical work than did private practice surgeons (24 hours [IQR, 14-38 hours] vs 9 hours [IQR, 4-17 hours]; P < .001). Academic surgeons were more likely than private practice surgeons to be satisfied with their career as a surgeon (1448 of 1706 [85%] vs 1109 of 1420 [78%]; P < .001) and their financial compensation (997 of 1703 [59%] vs 546 of 1416 [39%]; P < .001). Academic surgeons were less likely than private practice surgeons to feel that competition with other surgeons is a threat to financial security (341 of 1705 [20%] vs 559 of 1422 [39%]; P < .001) and less likely to feel that malpractice experience has decreased job satisfaction (534 of 1703 [31%] vs 686 of 1413 [49%]; P < .001). CONCLUSIONS AND RELEVANCE: This study suggests that, although overall surgeon satisfaction was high, academic surgeons reported higher career satisfaction on several measures when compared with private practice surgeons. Advocacy for private practice surgeons is important to encourage career longevity and sustain US surgeon workforce needs