Surgeons

The Safety Attitudes Questionnaire (SAQ) is a refinement of the Intensive Care Unit Management Attitudes Questionnaire, [14 (link),15 ] which was derived from a questionnaire widely used in commercial aviation, the Flight Management Attitudes Questionnaire (FMAQ). [16 ,17 ] The FMAQ was created after researchers found that most airline accidents were due to breakdowns in interpersonal aspects of crew performance such as teamwork, speaking up, leadership, communication, and collaborative decision making. The FMAQ measures crew member attitudes about these topics.
Because 25% of the FMAQ items demonstrated utility in medical settings in terms of the subject covered and factor loadings, they were retained on the SAQ, The new SAQ items were generated by discussions with healthcare providers and subject matter experts. In addition, we relied upon two conceptual models to decide which items to include: Vincent's framework for analyzing risk and safety [8 (link)] and Donabedian's conceptual model for assessing quality [18 (link)] This generated a pool of over 100 new items covering four themes: safety climate, teamwork climate, stress recognition, and organizational climate. Items were evaluated through pilot testing and exploratory factor analyses. This phase of survey development consistently yielded 6 factor-analytically derived attitudinal domains containing 40 items from the survey (two, three, four, and five factor structures were less robust). Three of the targeted themes, safety climate, teamwork climate, and stress recognition, emerged as factors. In particular, safety climate and stress recognition are conceptually quite similar to their counterparts in aviation. [19 ] The fourth targeted theme, organizational climate, consistently emerged as three distinct but related factors, perceptions of management, working conditions, and job satisfaction. Organizational climate plays a decisive role in setting the preconditions for success or failure in managing risks [3 ,4 (link),20 (link)] , and we therefore retained these three factors as part of safety attitude assessment. An additional 20 items were retained because they were deemed interesting and valuable to the unit managers and senior hospital leadership to whom we reported the results of our pilot studies.
The SAQ has been adapted for use in intensive care units (ICU) [15 ,21 ] , operating rooms (OR), general inpatient settings (medical ward, surgical ward, etc.), and ambulatory clinics. For each version of the SAQ, item content is the same, with minor modifications to reflect the clinical area. For example, "In this ICU, it is difficult to discuss mistakes," vs. "In the ORs here, it is difficult to discuss mistakes." The SAQ elicits caregiver attitudes through the 6 factor analytically derived climate scales: teamwork climate; safety climate; job satisfaction; perceptions of management; working conditions; and stress recognition (Figure 1).
The SAQ is a single page (double sided) questionnaire with 60 items and demographics information (age, sex, experience, and nationality). The questionnaire takes approximately 10 to 15 minutes to complete. Each of the 60 items is answered using a five-point Likert scale (Disagree Strongly, Disagree Slightly, Neutral, Agree Slightly, Agree Strongly). Some items are negatively worded. There is also an open-ended section for comments: "What are your top three recommendations for improving patient safety in this clinical area?" Each version of the SAQ in the current study includes a "Collaboration and Communication" section, where respondents are asked to indicate the quality of collaboration and communication they have experienced with each of the types of providers in their clinical area (e.g., Staff Surgeons, Surgical Residents, Staff Anesthesiologists, OR Nurses, etc.) using a five-point Likert scale (Very Low, Low, Adequate, High, Very High).

Subjects were recruited from an obesity treatment center in a university hospital in Taiwan. The obesity treatment center personnel comprised a multi-disciplinary team, and included a surgeon, internal physician, psychiatrist, urologist, obstetrics and gynecology doctor, nurse, case manager, dietician, and physical activity director. The obesity treatments in this center included non-surgical procedures: meal replacement, pharmacotherapy, psychiatric bio-feedback treatment and intra-gastric balloon, and surgery: bariatric surgery (sleeve, band, Roux-en-Y gastric bypass). First of all, the patients made up their mind as to the treatment modality. However, the patients who wanted to receive bariatric surgery had to meet the criteria of morbid obesity. They then needed to undergo a complete pre-operation evaluation, including a psychiatric evaluation. Our hospital has a committee in charge of determining whether the patients are eligible for bariatric surgery.
Patients received a complete physical evaluation during their first visit, and also completed two questionnaires: the Taiwanese Depression Questionnaire (TDQ) and the Chinese Health Questionnaire (CHQ). The TDQ is a 0-3-point, 18-question questionnaire used to screen clinical depressive disorder.
[22 (link)]. The cut-off point in the community population is 18/19 points. The CHQ
[23 (link)] is a 12-question, 2-reverse questions, 0-1-point questionnaire for screening “minor psychiatric disorders” such as anxiety disorder. The cut-off point in community surveys screening minor mental disorders is 4/5 points.
To avoid false negative results, we lowered the cut-off points for the CHQ and TDQ in our clinical practice. Those patients with CHQ <3 and TDQ <13 were regarded as having no psychiatric disorder. If any of the two scores were above the cut-off point (i.e., CHQ ≧3 or TDQ ≧13, or both), the patients would be referred to psychiatrists for further evaluation. The lifetime psychiatric diagnosis was made based on the psychiatrist’s diagnostic interview, using the Structured Clinical Interview for the DSM-IV (SCID).
We recruited all patients that visited the obesity treatment center of E-Da Hospital from January 2007 to December 2010. The exclusion criteria were age younger than 18 years, having incomplete BMI, TDQ or CHQ data, and refusal of psychiatric interview when needed.
All analyses were performed with the Statistical Package for Social Sciences, SPSS Version 17.0. The chi-square test was used to compare differences for categorical variables and the t-test was used to compare differences for continuous variables. The level of statistical significances was 0.05, two-tailed. Logistic regression was applied to examine whether BMI was associated with a psychiatric disorder.
This study was approved by the Institutional Review Board of E-Da Hospital, Taiwan (EMPR-098-073). The study design and performance complied with the Declaration of Helsinki.

A retrospective review was conducted of all 640,880 cases of TJA in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2012 to December 31, 2019. TJA cases were identified with the Current Procedural Terminology (CPT) codes 27,447 (total knee arthroplasty) and 27,130 (total hip arthroplasty). Exclusion criteria included unknown or not reported race, age 90 or older (as NSQIP groups these patients as age 90+), emergency cases, patients on preoperative dialysis, unknown preoperative creatinine, and unknown preoperative height or weight. A total of 143,619 cases were removed due to these criteria, resulting in a total of 497,261 cases included for analysis in this study (Fig. 1).Fig. 1

Flow diagram indicating study inclusion and exclusion criteria

Radiographic data consisted of full-length coronal and sagittal radiographs were obtained in free- standing posture with the upper limbs resting on a support, the shoulders at 30° forward flexion, and the elbows slightly flexed [19 (link)]. All of the radiographic parameters were measured with Surgimap Software (version: 2.3.2.1; Spine Software, New York, NY).
All of the radiographic parameters concerned in this current study were shown in the Fig. 1A-B, which included thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), sacral slope (SS), pelvic tilt (PT) and pelvic incidence (PI). All of those radiographic measurements were performed by a dedicated team independent from the operating surgeons.Fig. 1

A Sagittal radiologic parameters: Thoracic Kyphosis (TK) measured from the superior endplate of T4 to the inferior endplate of T12 by Cobb method; Lumbar Lordosis (LL) measured from the superior endplate of L1 to the inferior endplate of S1 by Cobb method. Sagittal vertical axis (SVA) defined as the horizontal offset from the posterosuperior corner of S1 to the plumb line going through the vertebral body of C7. B Pelvic parameters: Sacral slope (SS): the angle between the horizontal line and the sacarl endplate; Pelvic tilt (PT): the angle between the vertical and the line through the midpoint of the sacral endplate to the femoral heads axis; Pelvic Incidence (PI): the angle between the perpendicular to the sacral plate at its midpoint and the line connecting this point to the femoral heads axis

Kyphosis was recorded as positive value ( +), and lordosis as negative value (-). The spinopelvic index (SPI) was calculated by the equation: SPI = SS/PT.

A blood sample (approximately 6 mL) was drawn from the forearm vein into a tube containing an anticoagulant following overnight fasting on the day of surgery. The mixture was immediately centrifuged at 4000×g for 10 min at 4 °C. A vitreous sample (approximately 1 mL) was carefully collected into a 2 mL sterile syringe using a 25-gauge vitreous cutter and manual suction before opening the intraocular irrigation system. If vitreous hemorrhage was present, the surgeon avoided collecting blood components as much blood as possible. All samples were stored in cryopreservation tubes and immediately cooled at − 80 °C until analysis.
After sample collection, total RNA was extracted using TRIzol LS reagent (Invitrogen, Carlsbad, CA, USA) combined with miRNeasy Micro Kit (Qiagen, Hilden, Germany). RNA quality and integrity were measured using Nanodrop (Thermo Fisher Scientific, Waltham, MA, USA) and Agilent 4200 TapeStation.