Patients with CKD are more likely than others to have abnormalities in serum potassium (K(+)). Aside from severe hyperkalemia, the clinical significance of K(+) abnormalities is not known. We sought ...to examine the association of serum K(+) with mortality and hospitalization rates within narrow eGFR strata to understand how the burden of hyperkalemia varies by CKD severity. Associations were examined between serum K(+) and discontinuation of medications that block the renin-angiotensin-aldosterone system (RAAS), which are known to increase serum K(+).
A cohort of patients with CKD (eGFR<60 ml/min per 1.73 m(2)) with serum K(+) data were studied (n=55,266) between January 1, 2009, and June 30, 2013 (study end). Serum K(+), eGFR, and covariates were considered on a time-updated basis. Mortality, major adverse cardiovascular events (MACE), hospitalization, and discontinuation of RAAS blockers were considered per time at risk.
During the study, serum K(+) levels of 5.5-5.9 and ≥6.0 mEq/L were most prevalent at lower eGFR: they were present, respectively, in 1.7% and 0.2% of patient-time for eGFR of 50-59 ml/min per 1.73 m(2) versus 7.6% and 1.8% of patient-time for eGFR<30 ml/min per 1.73 m(2). Serum K(+) level <3.5 mEq/L was present in 1.2%-1.4% of patient-time across eGFR strata. The median follow-up time was 2.76 years. There was a U-shaped association between serum K(+) and mortality; pooled adjusted incidence rate ratios were 3.05 (95% confidence interval, 2.53 to 3.68) and 3.31 (95% confidence interval, 2.52 to 4.34) for K(+) levels <3.5 mEq/L and ≥6.0 mEq/L, respectively. Within eGFR strata, there were U-shaped associations of serum K(+) with rates of MACE, hospitalization, and discontinuation of RAAS blockers.
Both hyperkalemia and hypokalemia were independently associated with higher rates of death, MACE, hospitalization, and discontinuation of RAAS blockers in patients with CKD who were not undergoing dialysis. Future studies are needed to determine whether interventions targeted at maintaining normal serum K(+) improve outcomes in this population.
Background Hemodialysis patients with erythropoiesis-stimulating agent (ESA) hyporesponsiveness have been a topic of active research. However, there have been no studies of ESA hyporesponsiveness ...among US patients following the dramatic change in anemia management that resulted from the 2011 changes in ESA product labeling and bundling of dialysis remuneration. Study Design Retrospective observational study. Setting & Participants We studied prevalent hemodialysis patients treated at a large dialysis organization in calendar years 2012 to 2013 (N = 98,972). Predictor ESA hyporesponsiveness, defined as 2 consecutive hemoglobin measurements < 10 g/dL (every other week) with contemporaneous ESA dose > 7,700 U/treatment. Patients with ESA hyporesponsiveness were identified during the first quarter of 2012 and followed up through 2013 using intention-to-treat principles. Outcomes Associations between the study exposure (ESA hyporesponsiveness) and mortality, missed hemodialysis treatments, ESA and iron use, and hemoglobin levels were determined using generalized estimating equations adjusting for imbalanced baseline covariates. Results At baseline, 12,361 (12.5%) patients were identified as having ESA hyporesponsiveness. The mean hemoglobin level among patients with ESA hyporesponsiveness was ∼1 g/dL lower than in patients without ESA hyporesponsiveness at baseline, narrowing over follow-up to 0.4 g/dL. Initially, mean ESA use was approximately 3-fold greater for patients with ESA hyporesponsiveness than for those without ESA hyporesponsiveness, decreasing to 2-fold greater at study end; iron use and missed hemodialysis treatment rates were also greater among patients with ESA hyporesponsiveness throughout. ESA hyporesponsiveness was associated with enhanced mortality risk versus non–ESA hyporesponsiveness: adjusted incidence rate ratios were estimated at 2.24 (95% CI, 1.93-2.60) in the second quarter, gradually decreasing to 1.48 (95% CI, 1.18-1.84) by study end. Limitations It is possible that an alternative ESA hyporesponsiveness definition may be optimal. As such, the associations we observed may be conservative estimates of true relationships. Conclusions When using a contemporary definition at one point in time, ESA hyporesponsiveness was potently and persistently associated with greater mortality, greater iron and ESA use, and lower hemoglobin levels compared to non–ESA hyporesponsiveness.
Patients undergoing hemodialysis have an elevated risk of cardiovascular disease-related morbidity and mortality compared with the general population. Intradialytic hypotension (IDH) is estimated to ...occur during 20%-30% of hemodialysis sessions. To date, no large studies have examined whether IDH is associated with cardiovascular outcomes. This study determined the prevalence of IDH according to interdialytic weight gain (IDWG) and studied the association between IDH and outcomes for cardiovascular events and mortality to better understand its role.
This study retrospectively examined records of 39,497 hemodialysis patients during 2007 and 2008. US Renal Data System claims and dialysis provider data were used to determine outcomes. IDH was defined by current Kidney Disease Outcomes Quality Initiative guidelines (≥20 mmHg fall in systolic BP from predialysis to nadir intradialytic levels plus ≥2 responsive measures dialysis stopped, saline administered, etc.). IDWG was measured absolutely (in kilograms) and relatively (in percentages).
IDH occurred in 31.1% of patients during the 90-day exposure assessment period. At baseline, the higher the IDWG (relative or absolute), the greater the frequency of IDH (P<0.001). For all-cause mortality, the median follow-up was 398 days (interquartile range, 231-602 days). Compared with patients without IDH, IDH was associated with all-cause mortality (7646 events; adjusted hazard ratio, 1.07 95% confidence interval, 1.01 to 1.14), myocardial infarction (2396 events; 1.20 1.10 to 1.31), hospitalization for heart failure/volume overload (8896 events; 1.13 1.08 to 1.18), composite hospitalization for heart failure/volume overload or cardiovascular mortality (10,805 events; 1.12 1.08 to 1.17), major adverse cardiac events (MACEs; myocardial infarction, stroke, cardiovascular mortality) (4994 events, 1.10 1.03 to 1.17), and MACEs+ (MACEs plus arrhythmia or hospitalization for heart failure/volume overload) (12,221 events; 1.14 1.09 to 1.19).
IDH was potently associated with cardiovascular morbidity and mortality. Clinical trials to ascertain causality are needed and should consider reduction in IDWG as a potential means to reduce IDH.
Greater interdialytic weight gain (IDWG) is associated with risk of all-cause mortality and hospitalization. Dialysis patients are also at greater risk of cardiovascular (CV) events than patients ...without kidney disease. This retrospective study examined the potential association between IDWG and specific types of CV events.
Data were obtained from United States Renal Data System claims and the electronic health records of Medicare patients who initiated hemodialysis between 01 January 2007 and 31 December 2008 at a large dialysis organization. Absolute IDWG was defined as predialysis weight minus postdialysis weight from the prior treatment, and relative IDWG was calculated as percentage of postdialysis weight with mean values for each, calculated over dialysis days 91 to 180. Patient outcomes were considered beginning on day 181, continuing until death, discontinuation of care, censoring, or study end (31 December 2009). Outcomes included all-cause mortality, CV mortality, hospitalization for nonfatal heart failure/volume overload, hospitalization for nonfatal myocardial infarction, MACE (a composite measure of nonfatal myocardial infarction, nonfatal ischemic stroke, or CV death), and MACE+ (events comprising MACE as well as arrhythmia, nonfatal hemorrhagic stroke, or hospitalization for heart failure). Associations between IDWG and outcomes over the exposure period were estimated using proportional hazards regression and adjusted for baseline characteristics.
39,256 patients qualified for analysis. In general, associations of relative IDWG with outcomes were more potent, consistent, and monotonic than those for absolute IDWG. Relative IDWG > 3.5 % body weight was independently associated with all outcomes studied: point estimates ranged from 1.18 (myocardial infarction) to 1.26 (CV mortality) and were consistent among patients with and without diabetes, and with and without baseline heart failure. Absolute IDWG > 3 kg was associated with outcomes other than myocardial infarction: point estimates ranged from 1.11 (MACE) to 1.20 (heart failure).
Greater IDWG is associated with an increased risk of CV morbid events. Strategies that mitigate IDWG may improve CV health and survival among hemodialysis patients.
Background
Studies suggest that there are key differences in operative experience based on a trainee’s gender. A large-scale self-efficacy (SE) survey, distributed to general surgery residents after ...the American Board of Surgery In-Training Examination in 2020, found that female gender was associated with decreased SE in graduating PGY5 residents for all 4 laparoscopic procedures included on the survey (cholecystectomy, appendectomy, right hemicolectomy, and diagnostic laparoscopy). We sought to determine whether these differences were reflected at the case level when considering operative performance and supervision using an operative assessment tool (SIMPL OR).
Methods
Supervision and performance data reported through the SIMPL OR platform for the same 4 laparoscopic procedures included in the SE survey were aggregated for residents who were PGY5s in 2020. Independent
t
-tests and multiple linear regression were used to determine the relationship between trainee gender and supervision/performance ratings.
Results
For laparoscopic cases in aggregate (
n
= 2708), male residents rated their performance higher than females (3.57 vs. 3.26,
p
< 0.001, 1 = critical deficiency, 5 = exceptional performance) and reported less supervision (3.15 vs. 2.85,
p
< 0.001, 1 = show and tell, 4 = supervision only); similar findings were seen when looking at attending reports of resident supervision and performance. A multiple linear regression model showed that attending gender did not significantly predict resident-reported supervision or performance levels, while case complexity and trainee gender significantly affected both supervision and performance (
p
< 0.001).
Discussion
Female residents perceive themselves to be less self-efficacious at core laparoscopic procedures compared to their male colleagues. Comparison to more case-specific data confirm that female residents receive more supervision and lower performance ratings. This may create a domino effect in which female residents receive less operative independence, preventing the opportunity to establish SE. Further research should identify opportunities to break this cycle and consider gender identity beyond the male/female construct.
Graphical abstract
Introduction
A 2020 survey of post-graduate year 5 (PGY5) general surgery residents linked to the American Board of Surgery In-Training Examination (ABSITE) revealed significant deficits in ...self-efficacy (SE), or personal judgment of one’s ability to complete a task, for 10 commonly performed operations. Identifying whether this deficit is similarly perceived by program directors (PDs) has not been well established. We hypothesized that PDs would perceive higher levels of operative SE compared to PGY5s.
Methods
A survey was distributed through the Association of Program Directors in Surgery listserv; PDs were queried about their PGY5 residents’ ability to perform the same 10 operations independently and their accuracy of patient assessments and operative plans for components of several core entrustable professional activities (EPAs). Results of this survey were compared to PGY5 residents’ perception of their SE and entrustment based on the 2020 post-ABSITE survey. Chi-squared tests were used for statistical analysis.
Results
108 responses were received, representing ∼32% (108/342) of general surgery programs. Perceptions from PDs of PGY5 residents’ operative SE were highly concordant with resident perceptions; no significant differences were observed for 9 of 10 procedures. Both PGY5 residents and PDs perceived adequate levels of entrustment; no significant differences were observed for 6 of 8 EPA components.
Conclusions
These findings show concordance between PDs and PGY5 residents in their perceptions of operative SE and entrustment. Though both groups perceive adequate levels of entrustment, PDs corroborate the previously described operative SE deficit, illustrating the importance of improved preparation for independent practice.
Our aim was to identify gender and racial disparities in presidential leadership for national medical and surgical organizations.
We located publicly sourced information on national medical ...organizations. Years between or since the first diverse presidents were analyzed using descriptive statistics and Mann Whitney U tests.
Sixty-seven national medical and surgical organizations were surveyed. 70.8% (n = 34) diversified via gender first (White-female), whereas 26.1% (n = 14) had racial diversity first. Organizations with gender diversity first followed with an African American male president sooner than organizations who first diversified by race (14.7 ± 11.8 v. 27.6 ± 11.3 years, p = 0.018). No significant difference was observed for the third tier of diversification.
Significant gender and racial leadership disparities in national medical organizations are still present. It is notable that organizations with female leaders had a shorter timeline to racial diversity. These findings help to inform strategies to promote and increase diversity, equity, and inclusion in national leadership.
•Progress has been made in advancing diversity in national presidential leadership.•African American females are still largely underrepresented in presidential roles.•Organizations with female leaders have shorter timelines to racial diversity.•Diversity committees may help to further diversity in leadership roles.
Background
Implementation of the Fundamentals of Laparoscopic Surgery (FLS) by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for educational structure for ...laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy (SE) with laparoscopic procedures.
Methods
We conducted a national survey, linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9275 residents from 325 US General Surgery Training Programs participated. The online survey included multimodal questions that analyzed whether participants felt they could perform the most commonly-logged laparoscopic operations among residents Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), Laparoscopic Right Hemicolectomy (LRH), Diagnostic Laparoscopy (DL) without faculty assistance. This used a 5-point scaled assessment, ranging from “not able to” to “definitely able to.” Multivariate analyses determined if completion of FLS made a difference for resident self-efficacy, stratified by post-graduate year (PGY).
Results
At the time of the survey, 2300 reported completion of FLS. The percentage of FLS completion increased from PGY1 to PGY5 (4.2%
n
= 59 vs 85.8%
n
= 893). PGY1 residents who completed FLS, from 48 diverse institutions, demonstrated the most significant increases in SE
(p
< 0.05) with significantly higher perceived self-efficacy in LA (
p
= 0.001) and LRH (
p
= 0.012). PGY2 and PGY3 residents indicated increased SE in DL (
p
= 0.037,
p
= 0.015, respectively), based on FLS completion. These FLS effects were less evident in the more senior classes.
Conclusions
Completion of FLS arguably has the greatest benefits for more junior residents, as it establishes a foundation of laparoscopic knowledge and skill, upon which further residency training can build. Successful completion of the curriculum and assessment offered by the Fundamentals of Laparoscopic Surgery leads to greater sense of ability in early trainees.
Background
Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our ...study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally.
Materials and Methods
General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses.
Results
A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05).
Discussion
In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.
Variability in post-graduate year 5 (PGY5) residents' operative self-efficacy exists; yet the causes of variability have not been explored. Our study aims to determine resident-related and ...program-dependent factors associated with residents' perceptions of self-efficacy.
Following the 2020 American Board of Surgery In-Training Examination, a national survey of self-efficacy in 10 of the most commonly performed Accreditation Council for Graduate Medical Education case-log procedures was completed.
A total of 1,145 PGY5 residents completed the survey (response rate 83.8%), representing 296 surgical residency programs. Female sex (odds ratio OR 0.46 to 0.67; 95% CI 0.30 to 0.95; p < 0.05) was associated with decreased self-efficacy for 6 procedures. Residents from institutions with emphasis on autonomy were more likely to report higher self-efficacy for 8 of 10 procedures (OR 1.39 to 3.03; 95% CI 1.03 to 4.51; p < 0.05). In addition, increased socialization among residents and faculty also correlated with increased self-efficacy in 3 of 10 procedures (OR 1.41 to 2.37; 95% CI 1.03 to 4.69; p < 0.05). Procedures performed with higher levels of resident responsibility, based on Graduated Levels of Resident Responsibility (GLRR) and Teaching Assistant (TA) scores, were correlated with higher self-efficacy (p < 0.001).
Ensuring that residents receive ample opportunities for GLRR and TA experiences, while implementing programmatic support for resident-dependent factors, may be crucial for building self-efficacy in PGY5 residents. Institutional support of resident "autonomy" and increasing methods of socialization may provide a means of building trust and improving perceptions of self-efficacy. In addition, reevaluating institutional policies that limit opportunities for graduated levels of responsibility, while maintaining patient safety, may lead to increased self-efficacy.
PDF
