Tertiary Care Academic Center Research Articles

Consecutive Microsurgical Cases Performed by Single Surgeon at a Canadian Tertiary Care Center: A Retrospective Review

Background: The practice of a microsurgeon evolves over time with experience, changes in clinical interest, and practice setting. Previous reports suggest that complication rates may be influenced by years of practice. The aim of this study was to analyze consecutive microsurgical cases performed by a single surgeon during the first half of their career in a broad microsurgical practice at a Canadian academic tertiary care center. Methods: A retrospective chart review of all free tissue transfers between 2007 and 2020 completed by a single academic plastic surgeon was performed. The primary outcomes were the odds of postoperative complications and free flap failure. The secondary outcomes included the annual number and type of free flap cases over time. Results: The surgeon performed 795 free flaps on 537 patients. There were a total of 131 postoperative complications. There was no statistically significant association between the years in practice and odds of a complication. Overall, there were 26 flap failures, yielding a 96.7% success rate. There was no association between flap failure and years in practice. The most common type of reconstruction was breast, followed by lower extremity and head and neck. There was a significant change in the type of reconstruction cases over time ( P < 0.005). Conclusion: The type and volume of free flap reconstruction conducted by the surgeon has changed over time. In this single surgeon career, surgical experience did not have a significant impact on free flap complications. At our center, free tissue transfer remains a valuable tool for reconstruction in both low and high-risk patients.

The unnecessary workups and admissions of adolescents and young adults with spontaneous pneumomediastinum

Spontaneous pneumomediastinum (SPM) is a rare condition in children and young adults that raises concern for esophageal perforation or extension of an air leak, resulting in admissions with multiple interventions performed. To assess our outcomes, and to evaluate our resource utilization, we reviewed our experience with SPM. We conducted a retrospective review of SPM cases in patients aged 5–25 years old occurring between 2011 and 2021 at a single academic tertiary care center. Clinical, demographic, and outcome variables were collected and analyzed, and cohorts were compared using Fischer’s Exact Test and Welch’s T Test. 166 SPM cases were identified—all of which were Emergency Department (ED) presentations. 84% of the cases were admitted. 70% had Computerized Tomography (CT) scans, with no defined criteria for imaging. Comparison of floor admissions with discharges from the ED showed no significant difference in presenting symptoms, demographics, or outcomes between the two groups. Recurrence was noted in 4 patients with a range of 5.9 months–4.9 years from the initial episode. In the largest SPM study in the pediatric and young adult population, we noted no significant difference in management or outcomes in admitted or ED discharge patients nor those with CT imaging. Our results suggest that a large number of SPM can be managed safely with discharge from the ED.

BioPrev-C - development and validation of a contemporary prostate cancer risk calculator.

To develop a novel biopsy prostate cancer (PCa) prevention calculator (BioPrev-C) using data from a prospective cohort all undergoing mpMRI targeted and transperineal template saturation biopsy. Data of all men who underwent prostate biopsy in our academic tertiary care center between 11/2016 and 10/2019 was prospectively collected. We developed a clinical prediction model for the detection of high-grade PCa (Gleason score ≥7) based on a multivariable logistic regression model incorporating age, PSA, prostate volume, digital rectal examination, family history, previous negative biopsy, 5-alpha-reductase inhibitor use and MRI PI-RADS score. BioPrev-C performance was externally validated in another prospective Swiss cohort and compared with two other PCa risk-calculators (SWOP-RC and PBCG-RC). Of 391 men in the development cohort, 157 (40.2%) were diagnosed with high-grade PCa. Validation of the BioPrev C revealed good discrimination with an area under the curve for high-grade PCa of 0.88 (95% Confidence Interval 0.82-0.93), which was higher compared to the other two risk calculators (0.71 for PBCG and 0.84 for SWOP). The BioPrev-C revealed good calibration in the low-risk range (0 - 0.25) and moderate overestimation in the intermediate risk range (0.25 - 0.75). The PBCG-RC showed good calibration and the SWOP-RC constant underestimation of high-grade PCa over the whole prediction range. Decision curve analyses revealed a clinical net benefit for the BioPrev-C at a clinical meaningful threshold probability range (≥4%), whereas PBCG and SWOP calculators only showed clinical net benefit above a 30% threshold probability. BiopPrev-C is a novel contemporary risk calculator for the prediction of high-grade PCa. External validation of the BioPrev-C revealed relevant clinical benefit, which was superior compared to other well-known risk calculators. The BioPrev-C has the potential to significantly and safely reduce the number of men who should undergo a prostate biopsy.

Evaluation of a Radiological Tool for Semiautomatic Scalar Translocation Detection After Cochlear Implantation.

To evaluate the clinical applicability of a semiautomatic radiological tool for scalar translocation detection. Retrospective study. Tertiary care academic center. We included 104 patients implanted with 116 HiFocus Mid-Scala electrode arrays between January 2013 and September 2016. Cochlear implantation. The tool's scalar position assessments were compared with manual ones by calculating intraclass coefficient (ICC) for individual contacts and sensitivity and specificity for translocation detection of the whole array. In addition, ICC was calculated for diameters A and B, ratio A/B, and angular insertion depth (AID). Nine-one percent of cases could be processed, which took 5 to 10 minutes per case. Comparison of manual and semiautomatic scalar position showed for individual contacts an ICC of 0.89 and for the whole array a sensitivity of 97% and a specificity of 96%. ICCs for A, B, and A/B were 0.82, 0.74, and 0.39 respectively. For AID, ICC of each of the 16 contacts was 0.95 or higher. The semiautomatic radiological tool could analyze most cases and showed good to excellent agreement with manual assessments for translocation detection, diameter A, diameter B, and AID. The variability between semiautomatic and manual measurements is comparable to interobserver variability, indicating that clinical implementation of the tool is feasible.

Reading room assistants to reduce workload and interruptions of radiology residents during on-call hours: Initial evaluation

PurposeTo determine how much timesaving and reduction of interruptions reading room assistants can provide by taking over non-image interpretation tasks (NITs) from radiology residents during on-call hours. MethodsReading room assistants are medical students who were trained to take over NITs from radiology residents (e.g. answering telephone calls, administrative tasks and logistics) to reduce residents’ workload during on-call hours. Reading room assistants’ and residents’ activities were tracked during 6 weekend dayshifts in a tertiary care academic center (with more than 2.5 million inhabitants in its catchment area) between 10 a.m. and 5p.m. (7-hour shift, 420 min), and time spent on each activity was recorded. ResultsReading room assistants spent the most time on the following timesaving activities for residents: answering incoming (41 min, 19%) and outgoing telephone calls (35 min, 16%), ultrasound machine related activities (19 min, 9%) and paramedical assistance such as supporting residents during ultrasound guided procedures and with patients (17 min, 8%). Reading room assistants saved 132 min of residents’ time by taking over NITs while also spending circa 31 min consulting the resident, resulting in a net timesaving of 101 min (24%) during a 7-hour shift. The reading room assistants also prevented residents from being interrupted, at a mean of 18 times during the 7-hour shift. ConclusionThis study shows that the implementation of reading room assistants to radiology on-call hours could provide a timesaving for residents and also reduce the number of times residents are being interrupted during their work.

A129 OUTCOMES FOLLOWING ENDOSCOPIC SUBMUCOSAL DISSECTION OF SUPERFICIAL GASTROINTESTINAL TRACT NEOPLASTIC LESIONS FROM A TERTIARY-CARE ACADEMIC CENTRE

Abstract Background Endoscopic submucosal dissection (ESD) is an advanced luminal resection technique for dysplastic and early cancerous gastrointestinal (GI) tract neoplasms. By removing lesions en bloc, this method provides more accurate histopathologic evaluation of resection margins in comparison to endoscopic mucosal resection (EMR). Superior curative resection and lower recurrence rates over EMR have been shown in addition to the benefit of reduced morbidity and mortality compared to surgery. While ESD has become well-established in Asia and Europe, its adoption in North America – and in particular Canada – has been slowed by multiple technical and economic factors including a scarcity of infrastructure, institutional support, and standardized training. Additionally, reproduced Canadian data corroborating its known global efficacy is currently lacking. Aims Our aim was to evaluate clinical and technical outcomes in patients who underwent ESD of superficial GI tract neoplasms at a tertiary-care academic centre. Methods We conducted a retrospective single-centre cohort study at The Centre for Advanced Therapeutic Endoscopy & Endoscopic Oncology, St. Michael’s Hospital, Toronto, Canada. Consecutive adults (age ampersand:003E 18) who underwent ESD of any superficial GI tract neoplasm from October 2017 to December 2022 were included in the study. Primary outcomes were rates of en bloc, complete (R0), and curative resections. Secondary outcomes were rates of recurrence and adverse events. Data was collected through electronic chart review. Results ESD was performed in a total of 308 lesions with a mean size of 2.5 cm (range, 1-7 cm). Gastric ESD was the most common (n=130), followed by esophageal (n=91), rectal (n=62), and colonic (n=22). Three patients underwent duodenal ESD. En bloc, R0, and curative resection rates were 89.2%, 84.7%, and 71.8%, respectively. 64.3% of lesions were cancerous on pathology (n=198), of which 48 had at least submucosal invasion. Rates of delayed bleeding and deep mural injury (DMI) requiring surgical intervention were 3.9% and 1.3%, respectively. Overall recurrence at the first surveillance endoscopy (SE1) was 3.6%. Conclusions En bloc, R0, and curative resection rates reported from this largest single-centre Canadian ESD cohort are comparable to existing North American data. Low rates of early recurrence and an adequate safety profile have been demonstrated with this emerging oncologic method of resection. Additional investigation is warranted to optimize lesion selection and determine long-term clinical outcomes to further establish this technique in the management of superficial GI tract neoplasms. Table I. Procedural characteristics, outcomes, and adverse events for patients who underwent ESD of superficial GI tract neoplasms. Funding Agencies None

Reconstruction of the elbow with distal humerus endoprosthetic replacement after tumor resection: a systematic review of the literature and institutional case series

Distal humerus replacement (DHR) is a modular endoprosthesis mainly used for bone reconstruction after resection of primary or metastatic bone lesions. Studies on DHR failure rates and postoperative functional outcomes are scarce. We sought to assess implant survival, modes of failure, and functional outcomes in patients undergoing DHR for oncologic indications. A systematic review of the PubMed and Embase databases was performed. PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (457,260). Quality appraisal of included studies was conducted using the STROBE checklist. Prosthetic failure was assessed using the Henderson classification for megaprosthetic failures. We additionally performed a retrospective review of patients treated with a DHR for oncologic indications at a large tertiary care academic center. Weighted means were calculated to pool data. Eleven studies with a total of 162 patients met the inclusion criteria. Mean follow-up was 3.7years (range, 1.66-8years). Henderson type 2 failures (aseptic loosening) were the most common mode of failure, occurring in 12% of cases (range, 0%-33%). Five-year implant survival was 72% (range, 49%-93.7%). Mean postoperative Musculoskeletal Tumor Society (MSTS) score was 81.1 (range, 74-84.3). In our institutional case series, 2 out of 5 patients had DHR revision for periprosthetic fracture and aseptic loosening at 16 and 27months after surgery, respectively. Distal humerus replacement is a successful reconstruction strategy for tumors of the distal humerus, with high implant survival and good to excellent functional outcomes.

Outcome analysis of brain-death referral to NOD-Lb: A retrospective chart review of a single hospital experience over 3 years.

Organ donation shortage and in particular organ procurement is an international concern as the gap between the number of donors and recipients is steadily growing. Organ procurement is a chain of steps with donor identification and referral (ID&R) as the very first link in this chain. Failure of this step hinders the progress in the organ transplantation program. Our study was conducted to evaluate and highlight the gap between the national system and the practice at the identification and referral (ID&R) step of the organ procurement chain in a single tertiary-care academic health center in Beirut: the Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), and to appraise the literature for challenges at this step and for possible interventions for improvement based on the international experience. This retrospective study was a descriptive case series of ICU and ED deceased patients at a single tertiary-care university hospital in Beirut. Patients' characteristics were collected from medical records for all patients who died between 2017 and 2019 while in the ICU or the ED and shared with the National Organization for Organ and Tissue Donation and Transplantation (NOD-Lb), for each subject separately, to decide on the donor status. All data collected from the patient cohort was analyzed using R version 3.6.1. Wilcoxon signed-rank test, chi-squared, and fisher-exact tests were used to compare differences in clinical characteristics in terms of donor status when appropriate. This study served as 3 years audit of a single hospital experience, and it demonstrates failure to make any referrals to NOD-Lb and zero actual organ and tissue donations over the study period. The review of 295 deceased subjects' charts demonstrates 295 missed alerts to NOD-Lb and the overall missing of 5 organ and tissue donors and 24 cornea donors assuming the organ procurement chain of steps will continue uninterrupted after ID&R. The data gathered suggests the presence of an inefficient identification and referral system that is translated into a complete failure of reporting to NOD-Lb from LAUMC-RH. A systematic evidence-based approach to evaluate for the most cost-effective intervention to increase identification and referral rates is needed with a serious effort to examine and account for any inefficient implantation.

Safety and Efficacy of Midline vs Peripherally Inserted Central Catheters Among Adults Receiving IV Therapy

Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated. To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days. This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized. Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group. The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed. A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days. In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level. ClinicalTrials.gov Identifier: NCT04140916.

Effect of an Outbound Scheduling Team on the Timeliness of Scheduling Referrals to Pediatric Otolaryngology.

Families preferring to receive care in a language-other-than-English have disparities in access to care. We studied the effect of implementing an ambulatory outbound scheduling team on the timeliness of scheduling referrals to pediatric otolaryngology. We hypothesized this intervention could increase access to care. Retrospective cohort analysis. Tertiary care academic center. Data were abstracted from the hospital's enterprise database for patients referred to Otolaryngology over 3 years (October 2019-August 2022; 7675 referrals). An outbound scheduling team was created April 2021 and tasked with calling out to schedule referrals within one business day of receipt. Referral lag was compared across patient cohorts before and after the scheduling intervention. Log-transformed linear regression models were used to assess the impact of the scheduling intervention on referral lag for language cohorts. The median preintervention referral lag was 6 days (interquartile range [IQR] 2-18), which was reduced to 1 day postintervention (IQR 0-5; P < .001). Preintervention language-other-than-English families had a median referral lag of 8 days (IQR 2-23), which was 1.27 times higher than for patients speaking English (P < .001). With implementation of the scheduling intervention, language-other-than-English families were scheduled in a median of 1 day (IQR 0-6), and the disparity in timeliness of scheduling was eliminated (P = .131). Postintervention, referral lag was reduced by 58% in the English and 64% in the language other than English cohorts. Implementation of an outbound ambulatory scheduling process reduces referral lag for all patients and eliminated a disparity in referral lag for language-other-than-English families.

Utilization of Augmented Reality Head-Mounted Display for the Surgical Management of Thoracolumbar Spinal Trauma.

Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient's spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann-Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m2, CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.

Testing of a risk-stratified patient decision aid to facilitate shared decision-making for extended postoperative thromboprophylaxis after major abdominal surgery for cancer.

Use of extended pharmacologic thromboprophylaxis after major abdominopelvic cancer surgery should depend on best-available scientific evidence and patients' informed preferences. We developed a risk-stratified patient decision aid to facilitate shared decision-making and sought to evaluate its effect on decision-making quality regarding use of extended thromboprophylaxis. We enrolled patients undergoing major abdominopelvic cancer surgery at an academic tertiary care centre in this pre-post study. We evaluated change in decisional conflict, readiness to decide, decision-making confidence, and change in patient knowledge. Participants were provided the appropriate risk-stratified decision aid (according to their Caprini score) in either the preoperative or postoperative setting. A sample size calculation determined that we required 17 patients to demonstrate whether the decision aid meaningfully reduced decisional conflict. We used the Wilcoxon matched-pairs signed ranks test for interval scaled measures. We included 17 participants. The decision aid significantly reduced decisional conflict (median decisional conflict score 2.37 [range 1.00-3.81] v. 1.3 [range 1.00-3.25], p < 0.01). With the decision aid, participants had high confidence (median 86.4 [range 15.91-100]) and felt highly prepared to make a decision (median 90 [range 55-100]). Median knowledge scores increased from 50% (range 0%-100%) to 75% (range 25%-100%). Our risk-stratified, evidence-based decision aid on extended thromboprophylaxis after major abdominopelvic surgery significantly improved decision-making quality. Further research is needed to evaluate the usability and feasibility of this decision aid in the perioperative setting.

Prospective study examining the impact of cerebral angiography on quantitative pupillometer values in the interventional radiology suite

ObjectivesThe purpose of this pilot study was to obtain baseline quantitative pupillometry (QP) measurements before and after catheter-directed cerebral angiography (DCA) to explore the hypothesis that cerebral angiography is an...

Efficacy of noncarbapenem therapy for the treatment of ceftriaxone-resistant Enterobacterales outside the urinary tract.

To determine the safety of noncarbapenem versus carbapenem antibiotics for treatment of adults with documented infection caused by ceftriaxone-resistant infections outside the urinary tract. Retrospective cohort of adult patients with a documented infection caused by an extended-spectrum β-lactamase (ESBL)-producing organism isolated between January 2018 and October 2021. An academic tertiary-care center. Adult patients with a documented infection caused by an ESBL-producing organism outside the urinary tract. The primary outcome was a composite of treatment failure defined as 30-day mortality, 30-day readmission, microbiological recurrence, and/or clinical worsening requiring antibiotic change. Secondary outcomes included differentiation of primary composite components and postantibiotic Clostridioides difficile infection (CDI). This study included 130 patients. The primary source of infections were bloodstream (67.7%) and caused by Escherichia coli (81.5%). Overall, 101 patients received carbapenem therapy and 29 received noncarbapenem therapy (NCT). NCT was comprised of mainly fluoroquinolones (18 of 29) followed by cefepime (7 of 29). Patients receiving NCT had shorter hospital stays (median, 7 days vs 9 days) and were more often discharged on antibiotics (79.3% vs 50.5%). We did not detect a significant difference in the primary composite outcome of treatment failure for carbapenem (23.8%) versus noncarbapenem treatment (24.2%; P = .967). Secondary outcomes included a numerically higher 30-day mortality rate in the noncarbapenem group compared to the carbapenem group: 4 (13.8%) of 29 versus 4 (3.9%) of 101. We did not detect a difference in rates of CDI. Noncarbapenem therapy may play a role for certain patients with infections caused by ESBL-producing organisms.

Impact of Recombinant Granulocyte Colony-Stimulating Factor During Neoadjuvant Therapy on Outcomes of Resected Pancreatic Cancer.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease characterized by chronic inflammation and a tolerogenic immune response. The granulocyte colony-stimulating factor (G-CSF)-neutrophil axis promotes oncogenesis and progression of PDAC. Despite frequent use of recombinant G-CSF in the management and prevention of chemotherapy-induced neutropenia, its impact on oncologic outcomes of patients with resected PDAC is unclear. This cohort study assessing the impact of G-CSF administration was conducted on 351 patients with PDAC treated with neoadjuvant therapy (NAT) and pancreatic resection at a high-volume tertiary care academic center from 2014 to 2019. Participants were identified from a prospectively maintained database and had a median follow-up of 45.8 months. Patients receiving G-CSF (n=138; 39.3%) were younger (64.0 vs 66.7 years; P=.008), had lower body mass index (26.5 vs 27.9; P=.021), and were more likely to receive 5-FU-based chemotherapy (42.0% vs 28.2%; P<.0001). No differences were observed in baseline or clinical tumor staging. Patients receiving G-CSF were more likely to have an elevated (>5.53) post-NAT neutrophil-to-lymphocyte ratio (45.0% vs 29.6%; P=.004). G-CSF recipients also demonstrated higher circulating levels of neutrophil extracellular traps (+709 vs -619 pg/mL; P=.006). On multivariate analysis, G-CSF treatment was associated with perineural invasion (hazard ratio [HR], 2.65; 95% CI, 1.16-6.03; P=.021) and margin-positive resection (HR, 1.67; 95% CI, 1.01-2.77; P=.046). Patients receiving G-CSF had decreased overall survival (OS) compared with nonrecipients (median OS, 29.2 vs 38.7 months; P=.001). G-CSF administration was a negative independent predictor of OS (HR, 2.02; 95% CI, 1.45-2.79; P<.0001). In the inverse probability weighted analysis of 301 matched patients, neoadjuvant G-CSF administration was associated with reduced OS. In patients with localized PDAC receiving NAT prior to surgical extirpation, G-CSF administration may be associated with worse oncologic outcomes and should be further evaluated.

A Single Center Exploratory Survey of Patients and Nurses on post-Surgical Oral Opioid Delivery Through Patient-Controlled Analgesia.

The most common route of opioid delivery is nurse-administered pills. However, there are numerous challenges such as nursing burden, opioid diversion, medication delay, and patient dissatisfaction. In this study, we conducted two surveys, first to assess patients' and nurses' opinions on the current administration of opioids in pill form, followed by their attitudes towards an innovative concept of oral medication delivery based on a medical device currently undergoing research and development within the University, patient-controlled dispenser and deactivator (PCDD) that allows patients to self-administer liquid oral opioids on demand based on physician prescription. Questionnaires were developed, verified and deployed to assess nurse and post-surgical patient opinions on the current administration of opioids in pill form, as well as the proposed new concept of patient -controlled administration of oral liquid medication via an illustration of PCDD, from September 2022 through July 2023 at a major academic tertiary care center. Quantitative and qualitative data were collected from postoperative patients and nurses from surgical specialties including General Surgery, Surgical Oncology, Trauma Surgery, Orthopedics, and Neurosurgery. Forty-three patients and 53 nurses were interviewed. Seventy percent of patients frequently called nurses for pain medication post-surgery 1-4 times daily, and 32% of patients were told each day by nurses that they could not receive medication because they were not due yet. Medication delay caused 24% of patients to worry about nursing availability for medication delivery. Likewise, nurses reported that half of patients receive delayed medication (22 minutes median delay time) and half of nursing time was spent administering pain medication. Nurses expressed moderate satisfaction with their current delivery of medication (median satisfaction score 6.5 out of 10). When being introduced to the concept of PCDD via a product illustration, 15% of patients said that they prefer liquid medication and 51% said they prefer PCDD or were interested in trying it. Nurse-administered pills are a common but suboptimal method for postoperative pain management. Based on patient and nurse feedback, patient controlled self-administered liquid oral opioid delivery is conceptually innovative, practically viable and potentially a preferred alternative for timely and less nurse-exhaustive pain management.

Survey on the Perceptions of Pregnancy and Parenthood in Trainees: Advances, Obstacles, and Growth Opportunities

IntroductionDespite national policy changes, perspective changes on pregnancy and parenting in training are often lacking. We evaluated current viewpoints regarding pregnancy, parenthood, leave needs, and perceptions of support across trainees at our institution. MethodsA cross-sectional survey was sent to all residents and fellows at a tertiary care academic center with >700 trainees. Demographic information, opinions on maternity and paternity leave, and opinions on institutional support and career goals were collected. The survey was sent via the Graduate Medical Education Office listserv -- 66 Accreditation Council for Graduate Medical Education (ACGME) programs and 40 non-ACGME programs. ResultsSeven hundred and forty-seven house officers received the survey with a response rate of 21.9% (n = 164). Of respondents, 81% were residents and 99 respondents were female (representing 31% of female trainees at our institution). Thirty-seven point two percent of respondents reported being parents. Twenty-five point three percent of respondents had been pregnant while a trainee with no statistical difference by specialty type (P = 0.0817). Statistically significant difference was noted in having children based on sex with men becoming parents at twice the rate of women (56% vs 26%, P < 0.001). No difference was noted between specialties on perceived support while pregnant and peripartum. Thirty percent of parent respondents reported thinking about leaving medical training after having children given family stressors. Statistical difference in thoughts of leaving medicine overall between females (46%) and males (17.6%; P = 0.0238). ConclusionsMen and women need support as they navigate becoming parents at a naturally stressful transition period. Females consider leaving medicine at twice the rate of males after becoming parents. Our institution and other ACGME programs need greater transparency and consistent leave practices that reflect changing times.

Only as Strong as the Weakest Link: Resident Perspectives on Entrustable Professional Activities and Their Impact on Learning.

Background Core to competency-based medical education (CBME) is the use of frequent low-stakes workplace-based assessments. In the Canadian context, these observations of performance are framed around entrustable professional activities (EPAs). Objective We aimed to explore residents' real-world perspectives of EPAs and their perceived impact on learning, because assessments perceived to be "inauthentic," or not truly reflective of their lived experiences, may interfere with learning. Methods Using constructivist grounded theory, we conducted 18 semistructured interviews in 2021 with residents from all programs that had implemented CBME at one tertiary care academic center in Canada. Participants were recruited via email through respective program administrators. Data collection and analysis occurred iteratively, and categories were identified using constant comparative analysis. Results Residents were strikingly polarized, perceiving EPAs as either a valuable opportunity for professional growth or as an onerous requirement that interfered with learning. Regardless of what view participants held, all perspectives were informed by: (1) the program administration and the perceived messaging from program to residents; (2) faculty assessors and their perceived degree of engagement, or "buy-in" with the EPA system; and ultimately (3) learner behavior. We theorized from these findings that all 3 aspects must be working in tandem for the assessment system to function as intended. Conclusions From the learners' perspective, there exists a dynamic, interdependent relationship between the 3 CBME stakeholders. As such, the perceived value of the EPA assessment system can only be as strong as the weakest link in the chain.

Trial in Progress: Patient-Reported Outcome Measures in the Prospective Observational Cohort Study of Patients at Risk for Chronic Graft-Versus-Host Disease in the United States (THRIVE)

Background and Significance: Allogeneic hematopoietic cell transplantation (alloHCT) is a curative immunotherapy for patients with hematologic disorders. However, graft-versus-host-disease (GVHD) is a major limitation to the success of alloHCT, with chronic GVHD (cGVHD) as the leading cause of morbidity and mortality. The pleomorphic nature of cGVHD makes the diagnosis and patient management challenging for clinicians; thus, patient-reported symptoms often guide in diagnosing and determining the severity of cGVHD. Our current understanding of cGVHD is largely based on data from registries, single-institution prospective studies, and the cGVHD Consortium with representation from tertiary care academic centers. Prospective studies including patient-reported outcomes and a focus on a more representative and generalizable sample of patients with cGVHD are needed to better understand cGVHD symptoms, disease burden, and practice patterns for management. This trial in progress focuses on broad patient-centered assessment of post-alloHCT medical and psychosocial complications and patient-reported caregiver involvement in a diverse and contemporary patient population. This study uses multiple organ- or system-directed patient-reported outcome measures (PROMs) to help identify cGVHD symptoms, severity, and impact on patient quality of life including financial impact. The primary objective of THRIVE is to assess the clinical course and burden of cGVHD, including diagnosis and severity recorded in electronic case report forms (eCRFs) and PROMs. Secondary objectives include measuring healthcare resource utilization and patient economic and employment impact associated with cGVHD management, as well as patient-reported organ-specific symptoms. Study Design and Methods: THRIVE is a prospective, longitudinal, observational study (NCT05919511) of alloHCT recipients in the United States that uses a hybrid model designed to work with HCT centers and a virtual platform. Eligible patients are ≥18 years old, received alloHCT 90-180 days before enrollment, and are able to complete patient-assessment questionnaires provided in their preferred language either alone or with minimal caregiver assistance. Up to 1500 alloHCT recipients will be recruited at HCT sites (with the expectation that ~500 will have cGVHD symptoms at enrollment; ~500 are estimated to develop cGVHD during the course of the study; ~500 are estimated not to develop cGVHD during the study; Figure). Patients have the option to participate on a virtual platform. Patients will be followed for 36 months from date of enrollment or until the earliest of study termination, withdrawal, or death. Data from 13 PROMs (Table) divided into 3 groups will be collected every 3 months using a decentralized virtual platform. To reduce survey burden, patients will be randomized into 1 of 6 sequence groups to capture 4-5 PROMs per month in year 1 and every 2 months in years 2 and 3. Clinical data, including medications and adverse events, will be collected and abstracted into eCRFs every 3 months. In general, reporting of results will be descriptive for variables of interest. Summary statistics for continuous variables and for categorical variables will be calculated for all patients as well as for subgroups of interest. Whenever applicable, 95% confidence intervals will be calculated for endpoint estimates. Univariate, multivariate, or repeated-measurement analyses will be performed to assess factors associated with evolution of clinical manifestations of and complications from cGVHD. Recruitment for this study is ongoing.

Coping in Patients with Hematologic Malignancies Undergoing Hematopoietic Cell Transplantation

Background Patients undergoing hematopoietic cell transplantation (HCT) must cope with immense physical and psychological symptoms during HCT hospitalization, which contribute to a dramatic deterioration in quality of life (QOL). Yet, studies examining pre-HCT coping strategies are limited. We aimed to characterize use of pre-HCT coping strategies, to identify sociodemographic and clinical factors associated with coping strategy use, and to investigate the association of coping strategy use with pre-HCT QOL and psychological distress. Methods We conducted a secondary analysis of baseline data from a multi-site randomized controlled trial evaluating a supportive care intervention for patients with hematologic malignancies undergoing allogeneic or autologous HCT (NCT#03641378). From 10/2018 - 07/2022, the trial enrolled consecutive adults (age ≥ 18) with hematologic cancers undergoing HCT at three tertiary care academic centers. Prior to HCT, we assessed QOL (Functional Assessment of Cancer Therapy - Bone Marrow Transplant), psychological symptoms (Hospital Anxiety and Depression Scale and Post Traumatic Stress Disorder (PTSD) - Civilian Version), and coping (Brief COPE). We categorized coping as either “approach-oriented” (active coping, use of emotional support, positive reframing, acceptance) or “avoidant” (behavioral disengagement, denial, and self-blame). We used the median split method to categorize high and low use of approach-oriented and avoidant coping. Univariate logistic regression was used to identify sociodemographic and clinical factors associated with high use of coping strategies. Multivariate linear regression was used to measure associations of coping strategy use with QOL and psychological distress. Results Of pre-HCT patients (n=360), the majority were male (62.8%), identified as White (77.5%), were younger than 65 (73.6%), and had received at least some college education (78.9%). A minority were unemployed due to disability from illness (29.2%). Approximately half received autologous HCT (n=178, 49.4%). Figure 1 displays the proportion of patients scoring as high utilizers of individual coping strategies. While 31.3% were high utilizers of avoidant coping, 43.5% were high utilizers of approach-oriented coping. Notably, 43 (11.9%) patients identified as high utilizers of both approach-oriented and avoidant coping. No sociodemographic or clinical factors were associated with use of approach-oriented coping. Older age (&amp;gt;65 years, OR=0.9, p=0.01) and higher income (&amp;gt;$100K, OR=0.90, p=0.04) were associated with less frequent use of avoidant coping. Female gender (OR=1.11, p=0.03) and disabled employment status (OR=1.11, p=0.05) were associated with increased likelihood of high use of avoidant coping. Table 1 displays adjusted associations between approach-oriented and avoidant coping strategies and patient-reported outcomes. High use of approach-oriented coping was associated with better pre-HCT QOL (B=6.4, p&amp;lt;0.001) and lower depression (B=-1.1, p=0.001) and anxiety (B=-0.9, p=0.02) symptoms. High use of avoidant coping was associated with worse pre-HCT QOL (B=-11.7, p&amp;lt;0.001) and symptoms of depression (B=1.9, p&amp;lt;0.001), anxiety (B=3.1, p&amp;lt;0.001), and PTSD (B=8.1, p&amp;lt;0.001). Conclusions Prior to HCT, patients frequently employ approach-oriented and avoidant coping strategies. Key sociodemographic factors including age, gender, income level, and employment status were associated with avoidant coping. Patients with high use of approach-oriented coping reported higher baseline QOL and lower psychological distress, while those with high use of avoidant coping strategies reported worse QOL and psychological distress. These data suggest that supportive care interventions which enhance approach-oriented coping and mitigate avoidant coping in pre-HCT populations may improve QOL and reduce psychological distress