POTs: Protective Optimization Technologies

Algorithmic fairness aims to address the economic, moral, social, and political impact that digital systems have on populations through solutions that can be applied by service providers. Fairness frameworks do so, in part, by mapping these problems to a narrow definition and assuming the service providers can be trusted to deploy countermeasures. Not surprisingly, these decisions limit fairness frameworks' ability to capture a variety of harms caused by systems. We characterize fairness limitations using concepts from requirements engineering and from social sciences. We show that the focus on algorithms' inputs and outputs misses harms that arise from systems interacting with the world; that the focus on bias and discrimination omits broader harms on populations and their environments; and that relying on service providers excludes scenarios where they are not cooperative or intentionally adversarial. We propose Protective Optimization Technologies (POTs). POTs provide means for affected parties to address the negative impacts of systems in the environment, expanding avenues for political contestation. POTs intervene from outside the system, do not require service providers to cooperate, and can serve to correct, shift, or expose harms that systems impose on populations and their environments. We illustrate the potential and limitations of POTs in two case studies: countering road congestion caused by traffic-beating applications, and recalibrating credit scoring for loan applicants.Comment: Appears in Conference on Fairness, Accountability, and Transparency (FAT* 2020). Bogdan Kulynych and Rebekah Overdorf contributed equally to this work. Version v1/v2 by Seda G\"urses, Rebekah Overdorf, and Ero Balsa was presented at HotPETS 2018 and at PiMLAI 201

Upper Blepharoplasty

Upper blepharoplasty is one of the most commonly performed plastic surgical procedures. It can improve both form and function of a patient’s eyelids. The following chapter describes, in detail, the indications, preoperative markings, key intraoperative steps, and postoperative care of an upper blepharoplasty. This can be done in one’s office under local anesthesia, or under MAC or general anesthesia depending on comfort and preference of both the surgeon and patient

Female Genital Mutilation: Treatment Updates and the Need for Education

INTRODUCTIONFemale genital mutilation/cutting (FGM/C) refers to ritual surgical procedures performed that intentionally alter genitalia for nonmedical purposes. Female genital mutilation/ cutting is a lifelong problem for women that can have detrimental effects on menstruation, pregnancy, sexual health, and self-esteem. In 2016 the Centers for Disease Control and Prevention estimated 513,000 women and children in the United States were victims of or at risk for FGM/C. Currently, few studies discuss potential management options for FGM/C and their associated complications. Aims of this study are to review contemporary research on FGM/C, discuss current surgical therapies in the pediatric and adult populations, and draw attention to the urgent need for further education. METHODSThe authors conducted a literature review using PubMed, and identified 731 articles in the adult and pediatric populations. The articles were cross-referenced with 2 systematic reviews, and duplicates were discarded. Based on our criteria, 9 articles were included. RESULTSBased on our findings, defibulation offers patients a better quality of life with a low rate of complication. Similarly, clitoral reconstruction has shown favorable results for treatment of FGM/C. Using the Female Sexual Function Index can better help standardize measurements of sexual health outcomes. Currently, established clinical guidelines are lacking and there is limited training on the recognition and treatment of FGM/C. CONCLUSIONSThis study supports clitoral reconstruction and defibulation as effective therapies for FGM/C. Reconstructive surgeons are at the forefront of developing and providing these surgical treatments. Further research including randomized controlled studies and long-term follow-up are needed to better elucidate the best therapeutic options

Firearm injuries due to legal intervention in children and adolescents: a national analysis

Firearm injuries related to legal intervention have come under scrutiny because of recent events. The Kids' Inpatient Database (1997-2012) was searched for firearm injuries due to legal interventions (International Classification of Diseases, ninth revision, Clinical Modification E970) requiring inpatient admission in children aged <20 y. Cases were weighted to provide national estimates. The Brady Campaign criteria were used to identify lenient versus strict gun law states. Overall, 275 cases were identified, with a 7.5% mortality rate. Incidence peaked at 1.0 per 100,000 admissions in 2006, significantly increased from a low 0.2 per 100,000 admissions in 1997, P < 0.001. Patients were predominantly male (97%). African Americans (44%) represented the largest racial group, followed by Hispanics (30%) and Caucasians (20%). Mean age was 17.5 ± 2.08 y. Patients were insured by Medicaid (33%) or a private payer (24%); the remainder (43%) was uninsured. Admissions most frequently occurred at urban teaching hospitals (81%). Cases occurred most frequently in the Southern United States (44%), followed by the Western United States (35%). Most patients presented to non-children's hospitals (97%). Mean hospital admission cost was 27,507 ± 40,197 USD, whereas mean charges amounted to 75,905 ± 116,622 USD. Cases mostly occurred in lenient (56%) gun law states, whereas the remainder occurred in strict (41%) and neutral (3%) states. When analyzed by race, Caucasians (16%) had a significantly higher mortality rate when compared with African Americans (5%), P = 0.03. An analysis of this very specific injury mechanism demonstrates important findings, which are difficult to collect from conventional data sources. Future research will contribute to the objective analysis of this politically charged subject

Variations in Nationwide Readmission Patterns after Umbilical Hernia Repair

Up to one in three readmissions occur at a different hospital and are thus missed by current quality metrics. There are no national studies examining 30-day readmission, including to different hospitals, after umbilical hernia repair (UHR). We tested the hypothesis that a large proportion were readmitted to a different hospital, that risk factors for readmission to a different hospital are unique, and that readmission costs differed between the index and different hospitals. The 2013 to 2014 Nationwide Readmissions Database was queried for patients admitted for UHR, and cost was calculated. Multivariate logistic regression identified risk factors for 30-day readmission at index and different hospitals. There were 102,650 admissions for UHR and 8.9 per cent readmissions, of which 15.8 per cent readmissions were to a different hospital. The most common reason for readmission was infection (25.8%). Risk factors for 30-day readmission to any hospital include bowel resection, index admission at a for-profit hospital, Medicare, Medicaid, and Charlson Comorbidity Index ≥ 2. Risk factors for 30-day readmission to a different hospital include elective operation, drug abuse, discharge to a skilled nursing facility, and leaving against medical advice. The median cost of initial admission was higher in those who were readmitted ($16,560 [$10,805-$29,014]$11,752 [$8151-$17,724], < 0.01). The median cost of readmission was also higher among those readmitted to a different hospital ($9826 [$5497-$19,139]$9227 [$5211-$16,817], = 0.02). After UHR, one in six readmissions occur at a different hospital, have unique risk factors, and are costlier. Current hospital benchmarks fail to capture this subpopulation and, therefore, likely underestimate UHR readmissions

Nationwide risk factors for hospital readmission for subsequent injury after motor vehicle crashes

Objective: Some drivers involved in motor vehicle crashes across the United States may be identified as at risk of subsequent injury by a similar mechanism. The purpose of this study was to perform a national review of the risk factors for hospitalization for a new injury due to a subsequent motor vehicle crash. It was hypothesized that presenting to a different hospital after subsequent injury would result in worse patient outcomes when compared to presentation at the same hospital. Methods: The Nationwide Readmissions Database for 2010-2014 was queried for all inpatient hospitalizations with injury related to motor vehicle traffic. The primary patient outcome of interest was subsequent motor vehicle crash-related injury within 1 year. The secondary patient outcomes were different hospital subsequent injury presentation, higher Injury Severity Score (ISS), longer length of stay (LOS), and in-hospital death after subsequent injury. The analysis of secondary patient outcomes was performed only on patients who were reinjured. Univariable analysis was performed for each outcome using all variables during the index admission. Multivariable logistic regression was performed using all significant (P < .05) variables on univariate analysis. Results were weighted for national estimates. Results: During the study period, 1,008,991 patients were admitted for motor vehicle-related injury; 12,474 patients (1.2%) suffered a subsequent injury within 1 year. From the reinjured patients, 32.9% presented to a different hospital, 48.9% had a higher ISS, and 22.1% had a longer LOS. The in-hospital mortality rate after subsequent injury was 1.1%. Presentation to a different hospital for subsequent injury was associated with a longer LOS (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.20-1.45; P < .01) and a higher ISS (OR = 1.38; 95% CI, 1.27-1.49; P < .01). Motorcyclists were more likely to suffer subsequent injury (OR = 1.39; 95% CI, 1.32-1.46; P < .01) and motorcycle passengers were more likely to present to a different hospital with a subsequent injury (OR = 2.49; 95% CI, 1.73-3.59; P < .01). Alcohol abuse was associated with subsequent injury (OR = 1.12; 95% CI, 1.07-1.18; P < .01). Conclusions: Nearly a third of patients suffering subsequent motor vehicle crash-related injury after an initial motor vehicle crash in the United States present to a different hospital. These patients are more likely to suffer more severe injuries and longer hospitalizations due to their subsequent injury. Future efforts to prevent these injuries must consider the impact of this fragmentation of care and the implications for quality and cost improvements

Coverage of Fertility Preservation and Treatment Among Surgical Trainees in the United States of America

•Fertility preservation is gaining relevance among US surgical trainees, yet availability of fertility resources and institutional coverage of fertility services are lagging.•Current utilization of fertility services is low, but demand is high with almost 10-fold of trainees reporting interest should better insurance coverage become available.•Residency is a unique and limited window of opportunity to provide timely family planning support and coverage for our future surgeons. Both residents (avg. age 31.3 years) and fellows (avg. age 34.5 years) are within the crucial age period to consider oocyte cryopreservation as a family planning option.•Appropriate level of program support, and adequate coverage of family planning services are key to building a surgical workforce that has healthy work-life balance and is well physically, emotionally, and financially. Surgery trainees spend their prime fertility years in training, which leads to delays in childbearing, accompanying infertility challenges, and high-risk pregnancies. Literature report of institutional support for fertility preservation (egg/sperm freezing) and treatment is lacking. The cost is particularly prohibitive while receiving a resident physician salary. This study aimed to assess availability of fertility resources and institutional coverage of fertility services to US General Surgery Residents (GSR) and Breast Fellows. We composed and distributed a 26-question survey to GS residency and fellowship program directors nationwide to survey residents and fellows. Summary and descriptive statistics were tabulated, and categorical variables were analyzed using Pearson's chi square test. A total of 234 US surgical trainees (male n = 75, female n = 155, unreported n = 4) completed the survey. Total of 12 % of trainees reported having been counseled on family planning/fertility treatment during training, and only 5.1% were counseled on fertility preservation. Perceived lack of support from program (p = 0.027) and counseling of fertility preservation (p = 0.009) were significantly associated with female gender. A minority (12.5%) reported having insurance coverage for fertility preservation and 26% had coverage of fertility treatment. In addition, 2.6% respondents pursued fertility preservation while in training and 33% reported they would pursue fertility preservation if it was covered by insurance. Fertility preservation is rarely discussed in US General Surgery residency programs. The large majority of GSR lacks awareness of insurance coverage of fertility preservation and treatment. Strong efforts are necessary to improve fertility education for GSR and insurance coverage to meet trainee's needs