Leaning in and moving forward: a call to action and review of diversity initiatives in SAGES

BACKGROUND

Diversity, equity, and inclusion have been an intentional focus for SAGES well before the COVID-19 pandemic and the coincident societal recognition of social injustices and racism. Longstanding inequities within our society, healthcare, and the surgery profession have come to light in the aftermath of events that rose to attention around the time of Covid. In so doing, they have brought into focus disparities, injustices, and inequalities that have long been present in the field of surgery, selectively affecting the most vulnerable.

METHODS

This White paper examines the current state of diversity within the field of surgery and SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) approach and effort to pave the way forward to meaningful change. We delineate the imperative for diversity, equity, and inclusion for all. By all, we mean to be inclusive of the diversity of gender and sexual orientation, race, ethnicity, geography, sex, and disability in the field of surgery.

RESULTS

SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric.

CONCLUSION

True diversity, equity, and inclusion within a surgical organization is vital for its longevity, growth, relevance, and impact. Unfortunately, the absence of DEI limits opportunity, robs the organization of collective intelligence in an environment in which its presence is critical, contributes to health inequities, and impoverishes all within the society and its value to all with whom it interfaces. SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric. Strategies like those highlighted in this White Paper, may be within our grasp and we can learn yet more if we remain in a place of humility and teachability in the future.

Validation of transcutaneous bilirubinometry during phototherapy for detection and monitoring of neonatal jaundice in a low-income setting

Background: Severe neonatal jaundice (SNJ) and the associated long-term health sequelae are a significant problem in low-income countries (LIC) where measurement of total serum bilirubin (TSB) is often unavailable. Transcutaneous bilirubinometry (TcB) provides the opportunity for non-invasive, point-of-care monitoring. Few studies have evaluated its agreement with TSB levels during phototherapy in LIC.Aim: To determine agreement between TcB and TSB during phototherapy in a Haitian newborn population and to establish whether TcB can be safely used to guide treatment during phototherapy when TSB is unavailable.Methods: A single-centre prospective study (February to May 2017) in Cap Haïtien, northern Haiti was undertaken. Newborns <7 days of age with clinically detected jaundice were eligible for inclusion. A TcB device (JM-103) was used to screen for newborn jaundice along with a parallel TSB. A strip of black tape was placed across the sternum during phototherapy and uncovered for subsequent TcB measurements. Decisions about phototherapy treatment were based upon UK National Institute of Clinical Excellence (NICE) threshold criteria. Paired TSB and TcB measurements were compared using Bland-Altman methods.Results: The final analysis included 70 parallel TSB/TcB measurements from 35 infants within the first 5 days of life. Nineteen (54.3%) were male and 12 (34.3%) were <35 weeks. Thirty-two (91.4%) were receiving phototherapy. There was good agreement between TSB and TcB. Compared with TSB, TcB tended to over-estimate bilirubin (mean difference 11.1 µmol/L, 95% CI -10.2-32.5 µmol/L). However, at higher bilirubin levels (>250 µmol/L), TcB tended to under-estimate bilirubin compared with TSB and the difference increased.Conclusion: In an LIC setting in which serum bilirubin testing is not commonly available, TcB demonstrates good agreement with TSB and can be safely used to guide jaundice treatment during phototherapy but can lead to over-treatment at lower bilirubin levels and are more inaccurate at higher levels. For TcB levels >250 µmol, confirmation with serum bilirubin should be performed, if available, to avoid under-estimation.Abbreviations: LIC: low income countries; LMIC: low and middle income countries; TcB: transcutaneous bilirubinometry; TSB: transcutaneous serum biliubin.

Minimal information for studies of extracellular vesicles 2018 (MISEV2018): a position statement of the International Society for Extracellular Vesicles and update of the MISEV2014 guidelines

The last decade has seen a sharp increase in the number of scientific publications describing physiological and pathological functions of extracellular vesicles (EVs), a collective term covering various subtypes of cell-released, membranous structures, called exosomes, microvesicles, microparticles, ectosomes, oncosomes, apoptotic bodies, and many other names. However, specific issues arise when working with these entities, whose size and amount often make them difficult to obtain as relatively pure preparations, and to characterize properly. The International Society for Extracellular Vesicles (ISEV) proposed Minimal Information for Studies of Extracellular Vesicles ("MISEV") guidelines for the field in 2014. We now update these "MISEV2014" guidelines based on evolution of the collective knowledge in the last four years. An important point to consider is that ascribing a specific function to EVs in general, or to subtypes of EVs, requires reporting of specific information beyond mere description of function in a crude, potentially contaminated, and heterogeneous preparation. For example, claims that exosomes are endowed with exquisite and specific activities remain difficult to support experimentally, given our still limited knowledge of their specific molecular machineries of biogenesis and release, as compared with other biophysically similar EVs. The MISEV2018 guidelines include tables and outlines of suggested protocols and steps to follow to document specific EV-associated functional activities. Finally, a checklist is provided with summaries of key points.

Acute lymphoblastic leukaemia cells produce large extracellular vesicles containing organelles and an active cytoskeleton

Extracellular vesicles have been described in non-paracrine cellular interactions in cancer. We report a similar phenomenon in B-cell precursor (BCP) acute lymphoblastic leukaemia (ALL). Using advanced microscopy and high throughput screening, we further characterise a subset of large vesicles (LEVs) identified in cell lines, murine models of human BCP-ALL and clinical samples. Primary ALL blasts and cell lines released heterogeneous anucleate vesicles <6 micron into extracellular fluids. Larger LEVs were enclosed in continuous membranes, contained intact organelles and demonstrated an organised cytoskeleton. An excess of circulating CD19-positive LEVs were observed in diagnostic samples and isolated from mice engrafted with BCP-ALL primary cells. LEVs exhibited dynamic shape change in vitro and were internalised by other leukaemic cell lines leading to phenotypic transformation analogous to the cell of origin. In patient-derived xenografts, LEVs were released by primary ALL cells into extracellular spaces and internalised by murine mesenchymal cells in vivo. Collectively these data highlight the heterogeneity but accessibility of LEVs in clinical samples and their potential to provide a unique insight into the biology of the cell of origin and to their development as novel biomarkers to aid diagnosis and improve therapeutic outcomes.

A technique for re-utilizing catheter insertion sites in children with difficult central venous access

Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves "cutting-down" to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous "cut-down." A separate exit site is then created for the new catheter and it is tunneled to the "cut-down" site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring.

Reactivation of coccidioidomycosis: a prosthetic joint infection in Spain

A resident of Spain was found to have a prosthetic knee infection due to coccidioidomycosis. He had a history of having pneumonia which resolved while living in an area of California endemic for Coccidioides in 1957-1961. The patient left California in 1961 returned to Spain and never left Spain thereafter. In 2006, a total knee replacement was done. In 2013, a prosthetic knee infection was documented due to coccidioidomycosis. By molecular DNA analysis, Coccidioides immitis was identified from the knee tissue, a species most commonly found in California. This represents reactivation of a Coccidioides infection 56 years after leaving the endemic area.

Arm versus forearm tourniquet for carpal tunnel decompression - Which is better? A randomized controlled trial

Tourniquet pain is a common source of complaint for patients undergoing carpal tunnel decompression and practice varies as to the tourniquet position used. There is little evidence to suggest benefit of one position over another. Our aim was to compare patient and surgeon experience of forearm and arm tourniquets. Following a power calculation, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomized to either an arm or a forearm tourniquet. Measurements of blood pressure, heart rate and pain were taken at 2.5 min intervals. The operating surgeon also provided a visual analogue scale rating for the extent of bloodless field achieved and for any obstruction caused by the tourniquet. There was no statistically significant inter-group difference in patient pain or physiological response, tourniquet time, bloodless field or length of procedure. The degree of obstruction caused by the tourniquet was significantly higher in the forearm group.

LEVEL OF EVIDENCE

I. Prospective Randomized Controlled Trial.

A reliable surgical treatment for digital mucous cysts

There is no clear consensus about the best operative technique for the treatment of digital mucous cysts. We carried out a retrospective review of all patients who underwent excision of a digital mucous cyst using a local advancement skin flap over a 10-year period. A total of 69 patients were included and were reviewed at an average of 38 months (minimum 6 months) post-operatively. No patients were lost to follow-up. There was only one case of cyst recurrence. Of these 67 patients were happy with the scar and 63 patients said they would have the procedure again; 36 patients had a pre-operative nail deformity and 21 reported that the deformity grew out after the procedure.

Demonstration of Coccidioides immitis and Coccidioides posadasii DNA in soil samples collected from Dinosaur National Monument, Utah

Soil samples were collected in 2006 from Dinosaur National Monument (DNM), Utah, the site of an outbreak of coccidioidomycosis in 2001. DNA was isolated from two soil samples, and polymerase chain reaction (PCR) amplified Coccidioides DNA present in both samples. Ribosomal RNA genes and internal transcribed spacer (ITS) region PCR products were sequenced. Single-nucleotide polymorphisms indicated that the DNA from sample SS06RH was that of Coccidioides immitis, while the DNA from sample SS06UM was C. posadasii. This is the first report to directly demonstrate Coccidioides in soils from DNM and the first to report the presence of both C. immitis and C. posadasii in the same geographic location.

Lymphocytes from chronic lymphocytic leukaemia undergo ABL1-linked amoeboid motility and homotypic interaction as an early adaptive change to ex vivo culture

BACKGROUND

Those stimuli that together promote the survival, differentiation and proliferation of the abnormal B-lymphocytes of chronic lymphocytic leukaemia (CLL) are encountered within tissues, where together they form the growth-supporting microenvironment. Different tissue-culture systems promote the survival of the neoplastic lymphocytes from CLL, partly replicating the in vivo tissue environment of the disorder. In the present study, we focussed on the initial adaptive changes to the tissue culture environment focussing particularly on migratory behaviour and cellular interactions.

METHODS

A high-density CLL culture system was employed to test CLL cell-responses using a range of microscopic techniques and flow cytometric analyses, supported by mathematical measures of cell shape-change and by biochemical techniques. The study focussed on the evaluation of changes to the F-actin cytoskeleton and cell behaviour and on ABL1 signalling processes.

RESULTS

We showed that the earliest functional response by the neoplastic lymphocytes was a rapid shape-change caused through rearrangement of the F-actin cytoskeleton that resulted in amoeboid motility and promoted frequent homotypic interaction between cells. This initial response was functionally distinct from the elongated motility that was induced by chemokine stimulation, and which also characterised heterotypic interactions between CLL lymphocytes and accessory cells at later culture periods. ABL1 is highly expressed in CLL lymphocytes and supports their survival, it is also recognised however to have a major role in the control of the F-actin cytoskeleton. We found that the cytoplasmic fraction of ABL1 became co-localised with F-actin structures of the CLL lymphocytes and that the ABL1 substrate CRKL became phosphorylated during initial shape-change. The ABL-inhibitor imatinib mesylate prevented amoeboid movement and markedly reduced homotypic interactions, causing cells to acquire a globular shape to rearrange F-actin to a microvillus form that closely resembled that of CLL cells isolated directly from circulation.

CONCLUSION

We suggest that ABL1-induced amoeboid motility and homotypic interaction represent a distinctive early response to the tissue environment by CLL lymphocytes. This response is separate from that induced by chemokine or during heterotypic cell-contact, and may play a role in the initial entry and interactions of CLL lymphocytes in tissues.

Detection of coccidioidal antibodies in serum of a small rodent community in Baja California, Mexico

Coccidioidomycosis (Valley Fever) represents a serious threat to inhabitants of endemic areas of North America. Despite successful clinical isolations of the fungal etiological agent, Coccidioides spp., the screening of environmental samples has had low effectiveness, mainly because of the poor characterization of Coccidioides ecological niche. We explored Valle de las Palmas, Baja California, Mexico, a highly endemic area near the U.S.-Mexico border, where we previously detected Coccidioides via culture-independent molecular methods. By testing the serum from 40-trapped rodents with ELISA, we detected antibodies against Coccidioides in two species: Peromyscus maniculatus and Neotoma lepida. This study comprises the first report of wild rodent serum tested for coccidioidal antibodies, and sets the basis to analyze this pathogen in its natural environment and explore its potential ecological niche.

Case report: Abortion and disseminated infection by Coccidioides posadasii in an alpaca (Vicugna pacos) fetus in Southern California

Coccidioidomycosis is a fungal disease affecting humans and other mammals caused by the soil-dwelling fungi Coccidioides immitis and C. posadasii. Abortion due to Coccidioides spp. infection is rare in domestic animals and transplacental transmission is considered uncommon in women. This report describes a case of placental-fetal infection and abortion in an alpaca with disseminated C. posadasii infection. PCR amplification and DNA sequencing were used to confirm the etiology, C. posadasii, in fetal tissues.

Lesbian mothers and their children: the third wave

Research regarding lesbian mothers and their children has gone through a transformation in the last forty years. The first wave of research examined lesbians who had become parents while in heterosexual relationships. The second wave examined women who became parents within the context of lesbian relationships. Both of these waves focused on family functioning and child outcome, using heterosexual-headed families as comparison groups. The third wave of research, which is now underway, is focusing on the unique challenges faced by these families, and how lesbian mothers are creating and raising their families on their own terms. This article explores the research as it has evolved over the years and the direction in which it is headed.

Single incision Nuss procedure for pectus excavatum

PURPOSE

To describe a unique single incision modification of the Nuss procedure and compare results to a historical cohort of standard Nuss patients.

METHODS

A retrospective review of 32 patients who underwent the Nuss procedure at a tertiary academic medical center over a 4-year period (2007-2010). Fourteen consecutive patients who underwent the modified technique (MN) were compared to the previous 18 patients who underwent the standard procedure (SN). We evaluated for differences between group demographics, operative variables, and postoperative course. The major technical modification was performing the entire procedure through a single right lateral thoracic incision. The dissection for bar placement on the left side of the chest was performed in a subcutaneous, pre-sternal and pre-muscular plane from the right-sided incision. The bar was placed from the right side and positioned in the standard fashion. Thoracoscopy was preformed via the same incision using a 45-degree thoracoscope and multiple trocar positions. The bar was anchored to the chest wall with a unilateral bar stabilizer.

RESULTS

There were no statistically significant differences between the study groups in any of the patient, operative or postoperative care parameters.

CONCLUSION

The single incision modified Nuss procedure is as safe and efficacious as the standard technique.

Delta-opioid receptor activation prolongs respiratory motor output during oxygen-glucose deprivation in neonatal rat spinal cord in vitro

Delta opioid receptor (DOR) activation protects the adult mammalian brain during oxygen-glucose deprivation (OGD), but it is not known whether neonatal spinal motor circuits are also protected. Also, it is unclear whether the timing of spinal DOR activation relative to spinal OGD is important for neuroprotection. Thus, a split-bath in vitro neonatal rat brainstem/spinal cord preparation was used to record spontaneous respiratory motor output from cervical (C4-C5) and thoracic (T5-T6) ventral spinal roots while exposing only the spinal cord to OGD solution (0 mM glucose, bubbled with 95% N(2)/5% CO(2)) or DOR agonist drugs (DADLE, DPDPE). Spinal OGD solution application caused respiratory motor output frequency and amplitude to decrease until all activity was abolished (i.e. end-point times) after 25.9±1.4 min (cervical) and 25.2±1.4 min (thoracic). Spinal DOR activation via DPDPE (1.0 μM) prior-to and during spinal OGD increased cervical and thoracic end-point times to 35-48 min. Spinal DADLE or DPDPE (1.0 μM) application 15 min following spinal OGD onset increased cervical and thoracic end-point times to 36-45 min. Brief spinal DPDPE (1.0 μM) application for 10 min at 25 min before spinal OGD onset increased cervical and thoracic end-point times to 41-46 min. Overall, the selective DOR agonist, DPDPE, was more effective at increasing end-point times than DADLE. Naltrindole (DOR antagonist; 10 μM) pretreatment blocked DPDPE-dependent increase in end-point times, suggesting that DOR activation was required. Spinal naloxone (1.0 μM) application before and during spinal OGD also increased end-point times to 31-33 min, but end-point times were not altered by Mu opioid receptor (MOR) activation or DOR activation/MOR blockade, indicating that there are complex interactions between OGD and opioid signaling pathways. These data suggest DOR activation before, during, and after spinal OGD protects central motor networks and may provide neuroprotection during unpredictable perinatal ischemic events.

Changes in ventral respiratory column GABAaR ε- and δ-subunits during hibernation mediate resistance to depression by EtOH and pentobarbital

During hibernation in the 13-lined ground squirrel, Ictidomys tridecemlineatus, the cerebral cortex is electrically silent, yet the brainstem continues to regulate cardiorespiratory function. Previous work showed that neurons in slices through the medullary ventral respiratory column (VRC) but not the cortex are insensitive to high doses of pentobarbital during hibernation, leading to the hypothesis that GABA(A) receptors (GABA(A)R) in the VRC undergo a seasonal modification in subunit composition. To test whether alteration of GABA(A)R subunits are responsible for hibernation-associated pentobarbital insensitivity, we examined an array of subunits using RT-PCR and Western blots and identified changes in ε- and δ-subunits in the medulla but not the cortex. Using immunohistochemistry, we confirmed that during hibernation, the expression of ε-subunit-containing GABA(A)Rs nearly doubles in the VRC. We also identified a population of δ-subunit-containing GABA(A)Rs adjacent to the VRC that were differentially expressed during hibernation. As δ-subunit-containing GABA(A)Rs are particularly sensitive to ethanol (EtOH), multichannel electrodes were inserted in slices of medulla and cortex from hibernating squirrels and EtOH was applied. EtOH, which normally inhibits neuronal activity, excited VRC but not cortical neurons during hibernation. This excitation was prevented by bicuculline pretreatment, indicating the involvement of GABA(A)Rs. We propose that neuronal activity in the VRC during hibernation is unaffected by pentobarbital due to upregulation of ε-subunit-containing GABA(A)Rs on VRC neurons. Synaptic input from adjacent inhibitory interneurons that express δ-subunit-containing GABA(A)Rs is responsible for the excitatory effects of EtOH on VRC neurons during hibernation.

Somatic p16(INK4a) loss accelerates melanomagenesis

Loss of p16^INK4a–RB and ARF–p53 tumor suppressor pathways, as well as activation of RAS–RAF signaling, is seen in a majority of human melanomas. Although heterozygous germline mutations of p16^INK4a are associated with familial melanoma, most melanomas result from somatic genetic events: often p16^INK4a loss and N-RAS or B-RAF mutational activation, with a minority possessing alternative genetic alterations such as activating mutations in K-RAS and/or p53 inactivation. To generate a murine model of melanoma featuring some of these somatic genetic events, we engineered a novel conditional p16^INK4a-null allele and combined this allele with a melanocyte-specific, inducible CRE recombinase strain, a conditional p53-null allele and a loxP-stop-loxP activatable oncogenic K-Ras allele. We found potent synergy between melanocyte-specific activation of K-Ras and loss of p16^INK4a and/or p53 in melanomagenesis. Mice harboring melanocyte-specific activated K-Ras and loss of p16^INK4a and/or p53 developed invasive, unpigmented and nonmetastatic melanomas with short latency and high penetrance. In addition, the capacity of these somatic genetic events to rapidly induce melanomas in adult mice suggests that melanocytes remain susceptible to transformation throughout adulthood.

Self-regulation in the modification of disruptive classroom behavior

This study compared self-regulation and external regulation procedures in the treatment of children's disruptive classroom behavior. After baseline data were collected, three of the four most disruptive children in each of 10 first- and second-grade classrooms received reinforcement for achieving low rates of disruptive behavior. The fourth child served as a control subject throughout the experiment. Two of the three experimental subjects were then taught to self-observe their own disruptive behavior. In the final reinforcement period, these subjects were given control over dispensing reinforcers to themselves, based on their self-collected behavioral data while subjects in the other experimental group continued with the externally managed reinforcement. In extinction, reinforcement was discontinued for all subjects, but one of the self-regulation subjects in each classroom continued overtly to self-observe. Results indicated that both reinforcement programs reduced disruptive behavior. The self-regulation procedures were slightly more effective in reducing disruptiveness than was the external regulation procedure, and this advantage persisted into extinction. These results suggest that self-regulation procedures provide a practical, inexpensive, and powerful alternative in dealing with disruptive behavior in children.

Parental manipulation of child behavior in home observations

The object of this study was to investigate the extent to which parents can manipulate their children's behavior in home observations. Twelve families with four- to six-year old children were recruited for the research. The parents were instructed to make their child look "bad" or "deviant" on three days of a six-day observation and to look "good" or "nondeviant" on alternate days. Results indicated that, as predicted, the rate of child deviant behavior, parental negative responding, and parental commands were all significantly higher on bad than good days. Parental responses to questionnaires provided more detailed information on how parents felt that they influenced their children in the desired directions. These results were discussed in terms of their implications for child psychopathology and the methodology of data collection in the natural environment.